AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION This section must be completed for all Authorizations. Patient Name: Birth Date:

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Date: 2017-03-30 11:23:17		AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION This section must be completed for all Authorizations. Patient Name: Birth Date: Add to Reading List Source URL: bleckleymemorial.com Download Document from Source Website File Size: 299,18 KB Share Document on Facebook