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Home » Authorization To Protect And Share Your Medical-Information

  • Please list anyone that you authorize to have access to your (or your dependent’s) medical or financial records. This includes parents, spouses, dependents, domestic partners. If we receive a call regarding prescriptions, records, or financial information and the person is not listed below, privacy laws prevent us from discussing or releasing any information. If you do wish anyone to have access, you MUST list their name below. You may revoke this access at any time in writing. If you do not wish anyone to have access, leave this area blank.

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Leesville location coming soon!