Authorization Disclosure Form
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Furnish records to: Family Medical Care, 150 N New Castle St, New Wilmington, PA 16142
Furnish records to: Family Medical Care, 150 N New Castle St, New Wilmington, PA 16142
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*Right not to sign. You may refuse to sign this authorization. Refusal to sign this authorization will not affect your ability to obtain treatment by FMC, except in the case of health care that is solely for the purpose of creating health care information for disclosure to a third party (pre employment physical, life insurance physical, life insurance physical, research related care).
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.