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Disclosure and Release Form â Camp Template
Disclosure and Authorization â Split Form (English)
SAMPLE COMBINED DISCLOSURE AND AUTHORIZATION :
DISCLOSURE AND AUTHORIZATION FOR VOLUNTEERS [IMPORTANT -- PLEASE READ CAREFULLY
Jia Wang, MD 2121 Sage Road, Suite 180 Houston, TX 77056
REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION
to our employment application
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Document 44652
Contact us with any questions!: 423-775
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