I understand that this health information may include HIV ...
Lab Report_____ X-ray Report_____ Consultation Report_____ Other_____ Purpose of Disclosure: Changing Physician. Continuing Care. At My (patient) request. Second opinion. Legal. Insurance. School. Other_____ ... A photocopy of this form will be considered as valid as the original. 2. I understand that I may revoke this authorization at any time ... ................
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