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UNIVERSAL PATIENT AUTHORIZATION FORM FOR FULL …

form Florida AHCA FC4200-004 (July 1, 2011) , Page 1 of 2 UNIVERSAL PATIENT AUTHORIZATION form FOR FULL DISCLOSURE OF HEALTH INFORMATION FOR treatment AND QUALITY OF CARE **PLEASE READ THE ENTIRE form , BOTH PAGES.

medical treatment, or health insurance enrollment or eligibility for benefits. By signing this form, I voluntarily authorize, give my permission and allow use and disclosure: OF WHAT: ALL MY HEALTH INFORMATION including any information about sensitive conditions (if …

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