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Input Form:Deal with this potential dealer,buyer,seller,supplier,manufacturer,exporter,importer
(Any information to deal,buy, sell, quote for products or service)
Voluntary Authorization to Release Information This release is a voluntary consent to allow the above named referring agency to enter into ongoing discussion(s) with any of the departments agencies listed below The purpose of the discussion(s) is to allow the providing and or sharing of information necessary to provide ongoing services for the benefit of the undersigned Shared information, including my protected health information, will