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STANDARD AUTHORIZATION FORM
Records released pursuant to this authorization may include information concerning testing, diagnosis or treatment of HIV/AIDS, psychiatric and/or drug/alcohol
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74.052. Authorization Form for Release of Protected Information
Authorization Form for Release of Protected Information. Short Title. Official Text, 74.052. Authorization Form for Release of Protected Information.
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Authorization to Release Protected Health Information to a
Instructions: This form is to be used by a patient or legal representative to authorize the release of information to a third party (other than a family member.
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