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EFTA00306876
s. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Attorney K Court K Law Enforcement K Employer Other: Name: Address: Reason for Disclosure K Patient Request K Other: We will not condition treatment or payme
EFTA00313618
. (check one) do include do not include Psychiatric information. (check one) To 1Z Healthcare Provider O Insurance Company or Designee C Attorney K Court O Law Enforcement Other: Name: Dr. Bruce Moskowitz Address. 1411 N. Flagler Dr, Suite 7100, West Palm Beach. FL 33401 O Employer Reason for Di
EFTA01711860
. Recovery I Restitution • PELP X 0 Federal 0 Local K international Recovery Date: Cock • / Anitant 5 Code • ♦ Amount 3 Restitution Date: K Court Ordered 0 P'etnal Dversen Coco • Anoint 3 PELP Date: Code • Annout S • Dale Ptored v Dale Loaded Dale Loris- 5 Into Investigative Assistan