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\par }{\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \f43\fs4\insrsid8002064\charrsid4203986 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f43\insrsid8002064\charrsid4203986 Note: Fees may apply to certain requests\cell }{\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \b\f43\fs4\insrsid8002064\charrsid3483213 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid8002064\charrsid3483213 \trowd \irow0\irowband0\ltrrow\ts15\trrh158\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clpadt86\clpadft3\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow1\irowband1\ltrrow\ts15\trrh157\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1440\clpadt86\clpadft3\clshdrawnil \cellx6930\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4230\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f43\insrsid8002064\charrsid3483213 
Patient Name:  \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14501709\yts15 {\*\bkmkstart Text3}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 000000001400000005546578743300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 
\ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid8002064\charrsid3483213 {\*\bkmkend Text3}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 \trowd \irow1\irowband1\ltrrow\ts15\trrh157\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1440\clpadt86\clpadft3\clshdrawnil \cellx6930\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4230\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow2\irowband2\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx8370\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1260\clpadt86\clpadft3\clshdrawnil \cellx9630\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1530\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid8002064\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 Kaiser #\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 
\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14501709\yts15 {\*\bkmkstart Text4}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 
{\*\datafield 000000001400000005546578743400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20
\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 {\*\bkmkend Text4}\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 Date of Birth:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb
\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12279737\yts15 {\*\bkmkstart Text5}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid4203986 {\*\datafield 0010000000000000055465787435000000084d2f642f79797979000000000000000000}{\*\formfield{\fftype0\fftypetxt2{\*\ffname Text5}{\*\ffformat M/d/yyyy}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid12279737 \u8194
\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 {\*\bkmkend Text5}\cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid8002064\charrsid3483213 \trowd \irow2\irowband2\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx8370\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1260\clpadt86\clpadft3\clshdrawnil \cellx9630\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1530\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow3\irowband3\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 
Address:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text6}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 
 FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 000000001400000005546578743600000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text6}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid8002064\charrsid3483213 {\*\bkmkend Text6}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8002064\charrsid3483213 \trowd \irow3\irowband3\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow4\irowband4\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth540\clpadt86\clpadft3\clshdrawnil \cellx6030\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5130\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid6037369\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid6037369\charrsid3483213 City:
\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text7}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }
{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 000000001400000005546578743700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text7}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid6037369\charrsid3483213 {\*\bkmkend Text7}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid6037369\charrsid3483213 \trowd \irow4\irowband4\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth540\clpadt86\clpadft3\clshdrawnil \cellx6030\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5130\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow5\irowband5\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth630\clpadt86\clpadft3\clshdrawnil \cellx6120\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2455\clshdrawnil \cellx8575\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth965\clpadt86\clpadft3\clshdrawnil \cellx9540\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid7823696\charrsid3483213 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14501709\yts15 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid7823696\charrsid3483213 State:\cell 
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text8}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{
\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 000000001400000005546578743800000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text8}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid7823696\charrsid3483213 {\*\bkmkend Text8}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid7823696\charrsid3483213 
Zip Code:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14501709\yts15 {\*\bkmkstart Text9}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 
 FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 000000001400000005546578743900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text9}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid7823696\charrsid3483213 {\*\bkmkend Text9}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid7823696\charrsid3483213 \trowd \irow5\irowband5\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth630\clpadt86\clpadft3\clshdrawnil \cellx6120\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2455\clshdrawnil \cellx8575\clvertalt\clbrdrt\brdrnone \clbrdrl
\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth965\clpadt86\clpadft3\clshdrawnil \cellx9540\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil 
\cellx11160\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 
Phone #:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text10}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 
 FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text10}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid12204678\charrsid3483213 {\*\bkmkend Text10}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 \trowd \irow6\irowband6\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow7\irowband7\ltrrow\ts15\trrh222\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx6210\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16060865\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 
Email:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text11}{\field{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 
 FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text11}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid12204678\charrsid3483213 {\*\bkmkend Text11}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12204678\charrsid3483213 \trowd \irow7\irowband7\ltrrow\ts15\trrh222\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow8\irowband8\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx6570\clvertalt\clbrdrt\brdrnone 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4590\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \b\f43\fs4\insrsid14501709\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 
\b\f43\fs8\insrsid14501709\charrsid7614701 \cell }{\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \b\f43\fs4\insrsid14501709\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \f43\fs4\insrsid14501709\charrsid3483213 
\trowd \irow8\irowband8\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx6570\clvertalt\clbrdrt\brdrnone 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4590\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow9\irowband9\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar
\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid1005334\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 
\b\f43\fs28\insrsid1005334\charrsid3483213 Kaiser Permanente will not condition treatment, payment, enrollment or
\par eligibility for benefits on providing, or refusing to provide this authorization}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f43\fs28\insrsid1005334 
\par }{\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \b\f43\fs4\insrsid3483213\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid1005334\charrsid3483213 \trowd \irow9\irowband9\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow10\irowband10\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clpadt86\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3217101\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid4203986 This authorizes }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid1005334\charrsid10646742 the following Kaiser Permanente Medical Center(s):}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid4203986  {\*\bkmkstart Text1}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid4203986 {\*\datafield 
000000001400000005546578743100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid2775122\charrsid3217101 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}
\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid16060865\charrsid10646742 {\*\bkmkend Text1}\cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid1005334\charrsid4203986 Kaiser Permanente may disclose this information to:}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid16060865\charrsid4203986 
\par {\*\bkmkstart Check1}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid1005334\charrsid3483213  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid1005334\charrsid3483213 {\*\datafield 
010000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid1005334\charrsid3483213 {\*\bkmkend Check1} Check if same as above (disclosure to patient)\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid16060865\charrsid3483213 \trowd \irow10\irowband10\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clpadt86\clpadft3\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow11\irowband11\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmgf\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1710\clpadt86\clpadft3\clshdrawnil \cellx7200\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth3960\clpadt0\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3217101\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986 to disclose information as specified below for the following purpose(s): {\*\bkmkstart Text2}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid4203986\charrsid3217101  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\ul\insrsid4203986\charrsid3217101 {\*\datafield 000000001400000005546578743200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text2}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\ul\lang1024\langfe1024\noproof\insrsid4203986\charrsid3217101 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text2}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid4203986\charrsid3483213 Recipient Name:\cell 
}\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text12}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text12}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text12}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \trowd \irow11\irowband11\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmgf\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1710\clpadt86\clpadft3\clshdrawnil \cellx7200\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth3960\clpadt0\clpadft3\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow12\irowband12\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clpadt0\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \cell Address:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 
\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text13}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 
00000000140000000654657874313300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text13}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194
\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text13}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 
\trowd \irow12\irowband12\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4770\clpadt0\clpadft3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow13\irowband13\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth540\clpadt86\clpadft3\clshdrawnil \cellx6030\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5130\clpadt0\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 \cell City:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3375052\yts15 {\*\bkmkstart Text14}{\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text14}}}}}{\fldrslt {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text14}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \trowd \irow13\irowband13\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth540\clpadt86\clpadft3\clshdrawnil \cellx6030\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5130\clpadt0\clpadft3\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow14\irowband14\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth630\clpadt86\clpadft3\clshdrawnil \cellx6120\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2455\clpadt0\clpadft3\clshdrawnil \cellx8575\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth965\clpadt86\clpadft3\clshdrawnil \cellx9540\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 \cell State:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4676054\yts15 {\*\bkmkstart Text15}{\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313500000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text15}}}}}{\fldrslt {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text15}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 
Zip Code:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4676054\yts15 {\*\bkmkstart Text16}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313600000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text16}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text16}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \trowd \irow14\irowband14\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth630\clpadt86\clpadft3\clshdrawnil \cellx6120\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2455\clpadt0\clpadft3\clshdrawnil \cellx8575\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth965\clpadt86\clpadft3\clshdrawnil \cellx9540\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow15\irowband15\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2070\clpadt0\clpadft3\clshdrawnil \cellx8460\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx9180\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 \cell Phone #:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4676054\yts15 {\*\bkmkstart Text17}{\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313700000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text17}}}}}{\fldrslt {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text17}\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 Fax #:
\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4676054\yts15 {\*\bkmkstart Text18}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 
 FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313800000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text18}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text18}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \trowd \irow15\irowband15\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth900\clpadt86\clpadft3\clshdrawnil \cellx6390\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth2070\clpadt0\clpadft3\clshdrawnil \cellx8460\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx9180\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1980\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow16\irowband16\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx6210\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clpadt0\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 \cell Email:\cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4676054\yts15 {\*\bkmkstart Text19}{\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986 {\*\datafield 00000000140000000654657874313900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text19}}}}}{\fldrslt {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid4203986 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid4203986\charrsid3483213 {\*\bkmkend Text19}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid4203986\charrsid3483213 \trowd \irow16\irowband16\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvmrg\clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth720\clpadt86\clpadft3\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clpadt0\clpadft3\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow17\irowband17\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr
\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 
\f43\fs8\insrsid6037369\charrsid16610611 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid6037369\charrsid16610611 \trowd \irow17\irowband17\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrs\brdrw20 \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw20 \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrs\brdrw10 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow18\irowband18\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12279737\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid8664296\charrsid8664296 Copies of records or medical record information within the following dates:}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid8664296   {\*\bkmkstart Text20}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid12279737\charrsid2775122  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid12279737\charrsid2775122 {\*\datafield 
001000000000000006546578743230000000084d2f642f79797979000000000000000000}{\*\formfield{\fftype0\fftypetxt2{\*\ffname Text20}{\*\ffformat M/d/yyyy}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\ul\lang1024\langfe1024\noproof\insrsid12279737\charrsid2775122 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid8664296 {\*\bkmkend Text20} to {\*\bkmkstart Text21}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid12279737\charrsid2775122  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid12279737\charrsid2775122 
{\*\datafield 001000000000000006546578743231000000084d2f642f79797979000000000000000000}{\*\formfield{\fftype0\fftypetxt2{\*\ffname Text21}{\*\ffformat M/d/yyyy}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\ul\lang1024\langfe1024\noproof\insrsid12279737\charrsid2775122 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid8664296\charrsid3483213 {\*\bkmkend Text21}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \trowd \irow18\irowband18\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow19\irowband19\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4590\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx4590\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth3285\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx7875\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth3285\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Check2}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 
650000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 
\af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check2}  Both Hospital and Medical Office Records}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \cell {\*\bkmkstart Check3}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check3}  Medical Office Records}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 
\cell {\*\bkmkstart Check4}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check4}
  Hospital Records}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \trowd \irow19\irowband19\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4590\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx4590\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth3285\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx7875\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth3285\clpadl58\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow20\irowband20\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone 
\clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clpadl29\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Check5}
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 650000001400000006436865636b3500000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check5}
  Records limited to a specific provider: {\*\bkmkstart Text22}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid8664296\charrsid8664296  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid8664296\charrsid8664296 {\*\datafield 
00000000140000000654657874323200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text22}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\lang1024\langfe1024\noproof\insrsid8664296\charrsid8664296 \u8194\'20\u8194\'20\u8194
\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid8664296 {\*\bkmkend Text22} or department: {\*\bkmkstart Text23}}
{\field{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid8664296  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid8664296 {\*\datafield 00000000140000000654657874323300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20
{\*\ffname Text23}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\lang1024\langfe1024\noproof\insrsid8664296 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 {\*\bkmkend Text23}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 
\trowd \irow20\irowband20\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth11160\clpadl29\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow21\irowband21\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone 
\clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1890\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx1890\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth2700\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx4590\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth6570\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Check6}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 
650000001400000006436865636b3600000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check6}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 
\af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check6}  X-Ray films}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \cell {\*\bkmkstart Check7}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX 
}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 650000001400000006436865636b3700000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check7}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check7}  X-Ray Digital Images}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \cell 
{\*\bkmkstart Check8}}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\datafield 650000001400000006436865636b3800000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check8}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296 {\*\bkmkend Check8}
  Laboratory Results}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid8664296\charrsid3483213 \trowd \irow21\irowband21\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1890\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx1890\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth2700\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx4590\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth6570\clpadl29\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow22\irowband22\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone 
\clbrdrb\brdrs\brdrw30 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clpadl58\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11480921\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid9072440\charrsid9072440 NOTE: Hospital and Medical Office records may include disclosure of information related to mental health, alcohol/drug, and HI}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11480921 V}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid9072440\charrsid9072440  references contained within those records as part of this authorization.\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid9072440\charrsid3483213 \trowd \irow22\irowband22\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw30 \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clpadl58\clpadb58\clpadfl3\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow23\irowband23\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 
\clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \b\f43\fs8\insrsid15932195\charrsid795601 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 
\f43\fs4\insrsid15932195\charrsid15932195 \trowd \irow23\irowband23\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow24\irowband24\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone 
\clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clpadt43\clpadft3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid9072440\charrsid9072440 
The actual treatment records from mental health, or alcohol/drug departments, or results of HIV antibody tests are specifically protected, and will not be disclosed unless you sign below.\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid9072440\charrsid3483213 
\trowd \irow24\irowband24\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr
\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clpadt43\clpadft3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow25\irowband25\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl
\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4140\clpadt43\clpadft3\clshdrawnil \cellx4140\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth360\clshdrawnil 
\cellx4500\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth990\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw30 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 Mental Health department records}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f43\insrsid3438927 {\field{\*\fldinst SYMBOL 232 \\f "Wingdings" \\s 12}{\fldrslt\f10\fs24}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 Signature:}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10\brsp20 \brdrbtw\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3438927\yts15 {\*\bkmkstart Text24}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 {\*\datafield 00000000140000000654657874323400000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20
{\*\ffname Text24}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid3438927 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 {\*\bkmkend Text24}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \trowd \irow25\irowband25\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4140\clpadt43\clpadft3\clshdrawnil \cellx4140\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth360\clshdrawnil \cellx4500\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth990\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb
\brdrnone \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 
\af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 Alcohol / Drug dependency treatment records}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 
\cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid3438927 {\field{\*\fldinst SYMBOL 232 \\f "Wingdings" \\s 12}{\fldrslt\f10\fs24}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3438927 Signature:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10\brsp20 \brdrbtw\brdrs\brdrw10\brsp20 
\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3438927\yts15 {\*\bkmkstart Text25}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 {\*\datafield 
00000000140000000654657874323500000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text25}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid3438927 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194
\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 {\*\bkmkend Text25}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 
\trowd \irow26\irowband26\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth4140\clpadt43\clpadft3\clshdrawnil \cellx4140\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth360\clshdrawnil \cellx4500\clvertalt\clbrdrt\brdrnone 
\clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth990\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160
\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 HIV antibody test results}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f43\insrsid3438927 {\field{\*\fldinst SYMBOL 232 \\f "Wingdings"
 \\s 12}{\fldrslt\f10\fs24}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 Signature:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\brdrb\brdrs\brdrw10\brsp20 \brdrbtw\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3438927\yts15 {\*\bkmkstart Text26}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3438927  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927 {\*\datafield 00000000140000000654657874323600000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text26}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid3438927 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3438927\charrsid3483213 {\*\bkmkend Text26}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3438927\charrsid3483213 \trowd \irow27\irowband27\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4140\clpadt43\clpadft3\clshdrawnil \cellx4140\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth360\clshdrawnil \cellx4500\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth990\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb
\brdrnone \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow28\irowband28\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl
\brdrs\brdrw30 \clbrdrb\brdrs\brdrw30 \clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid15932195\charrsid795601 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid15932195\charrsid3483213 
\trowd \irow28\irowband28\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15932195\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrs\brdrw30 \clbrdrr
\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow29\irowband29\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv
\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw30 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw30 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160
\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 
\ltrch\fcs0 \f43\fs8\insrsid15932195\charrsid795601 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid15932195\charrsid795601 \trowd \irow29\irowband29\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw30 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw30 \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow30\irowband30\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13721640\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrs\brdrw30 
\clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clpadl29\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid5585724\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11367925   Media Type: }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid11367925  
{\*\bkmkstart Check9}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid11367925  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid11367925 {\*\datafield 
650000001400000006436865636b3900000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check9}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 
\af1 \ltrch\fcs0 \f43\insrsid11367925 {\*\bkmkend Check9}  Electronic     {\*\bkmkstart Check10}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925 
{\*\datafield 650000001400000007436865636b313000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check10}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925 {\*\bkmkend Check10}  Paper         }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11367925 Delivery Preference:}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid11367925   {\*\bkmkstart Check11}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925 {\*\datafield 
650000001400000007436865636b313100000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check11}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 {\*\bkmkend Check11}  Email/Secure Portal    }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid5585724  {\*\bkmkstart Check12}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 
 FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 {\*\datafield 650000001400000007436865636b313200000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check12}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 {\*\bkmkend Check12}  Mail     {\*\bkmkstart Check13}}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid152024  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 {\*\datafield 650000001400000007436865636b313300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check13}\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid152024 {\*\bkmkend Check13}  Pickup}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid11367925 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \trowd \irow30\irowband30\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13721640\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrs\brdrw30 \clbrdrb\brdrs\brdrw30 
\clbrdrr\brdrs\brdrw30 \cltxlrtb\clftsWidth3\clwWidth11160\clpadl29\clpadb29\clpadfl3\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow31\irowband31\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid11367925\charrsid795601 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid11367925\charrsid795601 
\trowd \irow31\irowband31\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrs\brdrw30 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow
}\trowd \irow32\irowband32\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid795601\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1800\clpadb58\clpadfb3\clshdrawnil \cellx1800\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth9360\clpadb58\clpadfb3\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f43\insrsid3353834\charrsid3353834 DURATION:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11367925\charrsid3353834 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3353834\yts15 {
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 This authorization shall remain in effect for one year from the date of signature unless a different date is specified here {\*\bkmkstart Text27}}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\ul\insrsid3353834\charrsid3353834  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\insrsid3353834\charrsid3353834 {\*\datafield 001000000000000006546578743237000000084d2f642f79797979000000000000000000}{\*\formfield{\fftype0\fftypetxt2{\*\ffname 
Text27}{\*\ffformat M/d/yyyy}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\ul\lang1024\langfe1024\noproof\insrsid3353834\charrsid3353834 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 {\*\bkmkend Text27} (date).}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid11367925\charrsid3483213 \trowd \irow32\irowband32\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid795601\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1800\clpadb58\clpadfb3\clshdrawnil \cellx1800\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth9360\clpadb58\clpadfb3\clshdrawnil \cellx11160\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 
\ltrch\fcs0 \b\f43\insrsid3353834\charrsid3353834 REVOCATION:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11367925\charrsid3353834 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 
You or your representative can revoke this authorization upon written request.  If you revoke, it will not affect information disclosed before the receipt of the written request.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \cell 
}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \trowd \irow33\irowband33\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid795601\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth1800\clpadb58\clpadfb3\clshdrawnil \cellx1800\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth9360\clpadb58\clpadfb3\clshdrawnil \cellx11160\row \ltrrow
}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 
\ltrch\fcs0 \b\f43\insrsid3353834\charrsid3353834 REDISCLOSURE:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f43\insrsid11367925\charrsid3353834 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 
Once this health information is disclosed, how the recipient further discloses it may no longer be protected under federal privacy law (HIPAA).  California recipients are required to obtain your authorization before further disclosing this information.}{
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid11367925\charrsid3483213 \trowd \irow34\irowband34\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid795601\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1800\clpadb58\clpadfb3\clshdrawnil \cellx1800\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth9360\clpadb58\clpadfb3\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow35\irowband35\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 
\trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb
\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 
\f43\fs4\insrsid11367925\charrsid3353834 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs4 \ltrch\fcs0 \f43\fs4\insrsid11367925\charrsid3353834 \trowd \irow35\irowband35\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow36\irowband36\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 
If you are requesting a form to be completed, we may substitute a standardized version of the form that provides the same or similar information requested.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3353834\charrsid3483213 \trowd \irow36\irowband36\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow37\irowband37\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 
\f43\fs12\insrsid6037369\charrsid3353834 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid6037369\charrsid3353834 \trowd \irow37\irowband37\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow38\irowband38\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 A copy of this authorization is as valid as an original.  I have the right to receive a copy of this authorization.}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \trowd \irow38\irowband38\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3353834\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth11160\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow39\irowband39\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 
\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 \f43\fs20\insrsid6037369\charrsid7614701 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs20 \ltrch\fcs0 
\f43\fs20\insrsid6037369\charrsid7614701 \trowd \irow39\irowband39\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow40\irowband40\ltrrow\ts15\trleft0
\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx1620\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx1890\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone 
\clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4050\clshdrawnil \cellx5940\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx6210\clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\*\bkmkstart Text28}{\field{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12279737  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid12279737 {\*\datafield 001000000000000006546578743238000000084d2f642f79797979000000000000000000}{\*\formfield{\fftype0\fftypetxt2{\*\ffname Text28}{\*\ffformat M/d/yyyy}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\lang1024\langfe1024\noproof\insrsid12279737 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3353834\charrsid3483213 {\*\bkmkend Text28}\cell \cell {\*\bkmkstart Text30}}{\field{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12279737  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12279737 {\*\datafield 
00000000140000000654657874333000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text30}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid12279737 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194
\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 {\*\bkmkend Text30}\cell \cell {\*\bkmkstart Text29}}{\field{\*\fldinst {\rtlch\fcs1 \af1 
\ltrch\fcs0 \f43\insrsid12279737  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid12279737 {\*\datafield 00000000140000000654657874323900000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text29}}}}}{\fldrslt {\rtlch\fcs1 
\af1 \ltrch\fcs0 \f43\lang1024\langfe1024\noproof\insrsid12279737 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz1\linex0\endnhere\sectlinegrid360\sectdefaultcl\sectrsid3483213\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3353834\charrsid3483213 {\*\bkmkend Text29}\cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \trowd \irow40\irowband40\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx1620\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil 
\cellx1890\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4050\clshdrawnil \cellx5940\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw20 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow41\irowband41\ltrrow
\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx1620\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx1890\clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl
\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4050\clshdrawnil \cellx5940\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx6210\clvertalt
\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3353834\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\f43\insrsid3353834 Date}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \cell \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834 Signature}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \cell \cell }{
\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid16610611 If not patient, print your name and relationship}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f43\insrsid3353834\charrsid3483213 
\trowd \irow41\irowband41\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16610611\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr
\brdrnone \cltxlrtb\clftsWidth3\clwWidth1620\clshdrawnil \cellx1620\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx1890\clvertalt\clbrdrt\brdrs\brdrw20 \clbrdrl
\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4050\clshdrawnil \cellx5940\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth270\clshdrawnil \cellx6210\clvertalt
\clbrdrt\brdrs\brdrw20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth4950\clshdrawnil \cellx11160\row \ltrrow}\trowd \irow42\irowband42\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6037369\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid6037369\charrsid795601 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs8 \ltrch\fcs0 \f43\fs8\insrsid6037369\charrsid795601 
\trowd \irow42\irowband42\ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\yts15 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 
\f43\fs12\insrsid16610611\charrsid16610611 SCAL: NS-9934 (6-12) SPANISH-NS-1614; CHINESE-NS-6274}{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid16060865 
\par }{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid16610611 NCAL: 90258 (REV. 6-12) SPANISH 01782-000; CHINESE 01782-002}{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid16610611\charrsid16610611 \cell }{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 
\f43\fs12\insrsid16060865 
\par }{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid16610611 ORIGINAL \endash  DISCLOSING PARTY       CANARY - PATIENT}{\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 \f43\fs12\insrsid16610611\charrsid16610611 \cell }\pard\plain \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f42\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\rtlch\fcs1 \af1\afs12 \ltrch\fcs0 
\f43\fs12\insrsid16060865\charrsid16610611 \trowd \irow43\irowband43\lastrow \ltrrow\ts15\trleft0\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth3\trwWidth11160\trftsWidthB3\trftsWidthA3\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid8664296\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth5490\clshdrawnil \cellx5490\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth5670\clshdrawnil \cellx11160\row }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \f43\insrsid9923090\charrsid3483213 
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