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ealth provider or entity to release this information: 8. Name and address of person(s) or category of person to whom this information will be sent: NYS OFFICE OF VICTIM SERVICES - AE SMITH BLDG., 80 S. SWAN ST., ALBANY, NY 122104002 9(a). Specitic information to be released: 0 Medical Record from (insert date) to (insert dat
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