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7) New Patients: Alternate Phone/Person

Authorization to Leave Personal Health Information by Alternate Means

I hereby authorize Home Towne Family Medicine to leave detailed, personal health information by the following means: (Please check all that apply)

Enter in Name and Contact Number
Enter in Name and Contact

With my signature below, I acknowledge and understand that this information will be kept in my medical records and the above parameters will remain in effect until revoked by me in writing. It is my responsibility to notify my healthcare provider (s) should I wish to change one or more of the telephone numbers and/or contacts listed above.

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