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I authorize the release of my confidential protected health information, as described in my directions above.
172 North Division Street Auburn, New York 13021 Phone # 1-800-233-3799 Fax back to 315-253-4338 One Time Credit Card Payment Authorization Form Sign and complete this form to authorize Gallace Auto Dismantling d/b/a Kubis Auto Parts to make a one time debit to your credit card listed below.
I (we) hereby authorize DK Distributors DBA PagGo Distributors, LLC to credit this bank account due to me, in accordance with the Agreement for payment due to me (us) on dates specified in accordance with the Agreement.
I, (Patient’s name)_________________________________________________, authorize McLean County Foot and Ankle to use my PHI (protected health information) and any imaging for educational and research purposes, including distribution of those recordings and information by any tangible of digital media (e.g.