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Release of Information Authorization

I understand that I have a right to cancel / revoke this authorization at any time. I understand that if I cancel / revoke this authorization I must do so in writing and present my written cancellation / revocation to the Health Information Services Department (Medical Records).

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Authorization for Release of Med Inf 12 16 08 …

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I hereby authorize and request the disclosure to the county assistance office any information concerning the age, residence, citizenship, employment, applications for employment, education

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