AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL …
an authorization to use or disclose psychotherapy notes may not be combined with another authorization except one to use or disclose psychotherapy notes. PRIVACY ACT STATEMENT SECTION I - PATIENT DATA 1. NAME (Last, First, Middle Initial) 2. DATE OF BIRTH (YYYYMMDD) 3. SOCIAL SECURITY NUMBER 4. PERIOD OF TREATMENT: FROM - TO (YYYYMMDD) 5. ................
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