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Authorization to Share Information

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Indicate below the people with whom Attentive Home Care may or may not share your protected personal health information.

Note: Attentive Home Care will share information as stated in the Notice of Use Disclosure Practices.
Attentive Home Care may share my protected health information with the following (initial all that pertain and the names of the individuals by category
I do not want my protected personal health information shared with anyone
I do not want my protected personal health information shared with the following specific people:
Please list here
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