PDF Applicant Authorization for Use and Disclosure of Personal ...

Patient's Original Signature _____ Date Please complete all information (both sides). Incomplete forms will be returned. M M D D Y Y Y Y M M D D Y Y Y Y M MD D Y Y Y Y PO Box 690 Horsham, PA 19044-9979 For inquiries, please call 800-727-5400 Use a Black or Blue Pen *You do not have to be a US citizen. ....

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