Information To Help You Fill Out The Page 2
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5If you change your mind and don't want Medicare to give out your personal health
7.
information, write to the address shown under number six on the authorization form and
tell Medicare. Your letter will revoke your authorization and Medicare will no longer
give out your personal health information (except for the personal health information
Medicare has already given out based on your permission).
You should make a copy of your signed authorization for your records before mailing it to
Medicare.
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