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DHS-25M-CL Rev. 4/05 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES CLIENT S NAME Department of Human Services Dear Healthcare Provider The attached is the new DHS Authorization for Disclosure/Use of Health Information Form DHS25M. Section VI Specific information the patient does NOT want disclosed. 9. A copy of the completed Form DHS-25M will be given to the patient. Specific Information I do NOT want disclosed check...
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dhs 25m form
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