Age 18-20 Release of Information Form

Please correct the errors described below.

I (insert name below) give permission for Bloomington Pediatrics, LTD to release information to the following persons:

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This consent will expire when the patient reaches 21 years of age. A new form must be completed by the patient at that time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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