http://www.centerstreetclinic.org/assets/dental-packet.pdf WebI authorize Center Street Community Health Center (CSCHC) and Morrow Family Health Center (MFHC), Galion Family Health Center (GFHC) to use and disclose my following Protected Health Information (PHI) listed below for the purposes listed elsewhere on the page. List individuals you would allow us to share medical information with if necessary.
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