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You should enter the essential information in the PO, BOX to, insert, date x, Other, ENTIRE, MEDICAL, FILE Include, Indicate, by, Initialing CoBy, initialing here, I, authorize HIV, Related, Information or, a, governmental agency, listed, here Initials, Name, of, individual, healthcare, provider I, Reason, for, release, of, information and Authority, to, sign, on, behalf, of, patient field.

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