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Page 1: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 2: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 3: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 4: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 5: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 6: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 7: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska
Page 8: Full page photo - Pain Center...This authorizes Nebraska Spine + Pain Center to release your protected health information. You only need to complete this portion if you want Nebraska

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