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Please list the family members, close friends, or other people who we can notify regarding your care or with who we can discuss your protected health information. Protected health information consists of test results, diagnoses, billing information, insurance information and treatment options. This form will be effective until you provide further notice to us.
(If patient is a minor, this must be a parent or guardian)
I acknowledge my protected health information can be released to the people I have listed above. I have the right to revoke this form at any time in writing at the office listed above.
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