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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH …

Side 2 – Authorization to Disclose Protected Health Information (Continued) Rev. 01/2013 I understand that: 1. I may refuse to sign this authorization and that it is strictly voluntary. 2. If I do not sign this form, my health care and the payment for my health care will not be affected.

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  Health, Information, Authorization, Protected, Disclose, Authorization to disclose protected health information, Authorization to disclose protected health

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