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Consent To Release Information Form. As it otherwise relates to this consent. Enter the name and address of the facility or person that is the custodian of the information requested.
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Enter the name of the person giving consent. As it otherwise relates to this consent. It may be necessary to prepare a consent form for each provider if there are multiple providers with medical, mental health or substance abuse records that need.
As It Otherwise Relates To This Consent.
Enter the name and address of the facility or person that is the custodian of the information requested. It may be necessary to prepare a consent form for each provider if there are multiple providers with medical, mental health or substance abuse records that need. I further understand and agree to all information and ramiications of the pennsylvania child abuse history certiication application.
I Have Read This Consent/Release Of Information Authorization Form And Fully Understand And Agree To Its Content.
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