Authorizations For Use Or Disclosure Of Medical Record Information Page 2

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Authorizations For Use or Disclosure of Medical Record Information
** By my signature, I attest that I am the legally responsible representative of the above mentioned patient in accordance with the following:
_______________________________________________________________________________________________________________________________.
The information released pursuant to this Authorization may be re-disclosed by the receiving institution or individual or other individuals or organizations that
are not subject to privacy protection laws. ECW will not condition treatment or payment of the provision of this Authorization. Patient does have the right to
receive a copy of this form

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