Sparks Eye Care - Permission to Disclose Medical Information

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    • I authorize Sparks Eye Care LLC to discuss or release health information identifying me to the following individuals/entities:

  • NameRelationship to Patient 
    • This authorization to disclose MEDICAL AND FINANCIAL information is being made voluntarily and at my request.

    • In signing this authorization, I understand and acknowledge the following (Initial in the space provided):
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  • I affirm I have read and understand the above information.

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