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PRIVACY ACT STATEMENT - HEALTH CARE RECORDS THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU. 1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN) S
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Document Date: 2010-04-30 14:27:19


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IndustryTerm

law enforcement / /

MedicalCondition

communicable disease / /

Organization

AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER / /

Position

Executive / /

SocialTag