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This form is used to request that the client's personal and protected health records with Quality Youth Services be released to a third party or to the client, or both. This form can also be used in order for a third party to share their personal and protected health records for a client with Quality Youth Services. These forms are usually signed so Quality Youth Services can speak with a third-party regarding the client. Care is made to release only what is necessary to that third party or vice versa.

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