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I hereby voluntarily authorize the disclosure of information from my health record. Name of Patient II. If this authorization has not been revoked it will terminate one year from the date of my signature unless a different expiration date or expiration event is stated. Specify new date 1 research related or 2 provided solely for the purpose of creating Protected Health Information for disclosure to a third party. 6. Section V if a different expiration date is desired specify a new date. 7. Sect ...

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