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  • Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
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Page 1: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 2: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 3: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 4: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 5: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 6: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 7: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 8: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 9: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 10: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)
Page 11: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

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Credit Card Authorization Formtricountypump.net/wp-content/uploads/2015/11/ccauth... · 2016-06-08 · Credit Card Authorization Form I/We authorize Tri County Pump Company to charge