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AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

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I authorize to release healthcare information to:
with the Most Recent:
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Note: * Please Fax: 1-708-283-1250
If there are any questions or clarifications, please contact us at 708-283-2600

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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