div class=ts-pagebutton class=gotoPage data-page=1Page 1button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=1 data-page=1 class=ts-thumb lazyload alt=Page 1: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails1jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=2Page 2button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=2 data-page=2 class=ts-thumb lazyload alt=Page 2: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails2jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=3Page 3button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=3 data-page=3 class=ts-thumb lazyload alt=Page 3: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails3jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=4Page 4button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=4 data-page=4 class=ts-thumb lazyload alt=Page 4: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails4jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=5Page 5button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=5 data-page=5 class=ts-thumb lazyload alt=Page 5: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails5jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=6Page 6button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=6 data-page=6 class=ts-thumb lazyload alt=Page 6: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails6jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=7Page 7button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=7 data-page=7 class=ts-thumb lazyload alt=Page 7: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails7jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=8Page 8button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=8 data-page=8 class=ts-thumb lazyload alt=Page 8: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails8jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=9Page 9button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=9 data-page=9 class=ts-thumb lazyload alt=Page 9: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails9jpg width=140 height=200 divdivdiv class=ts-pagebutton class=gotoPage data-page=10Page 10button div class=ts-imageimg data-url=mygyn-sh-20190107113130-i-request-and-authorize-brooksville-hma-llc-and-its-personnelhtmlpage=10 data-page=10 class=ts-thumb lazyload alt=Page 10: MyGYN SH-20190107113130 · I request and authorize Brooksville HMA LLC and its personnel to deliver medical care to my child listed below Guardians Name Print: Relationship to loading=lazy src=data:imagegifbase64iVBORw0KGgoAAAANSUhEUgAAAAIAAAACCAQAAADYv8WvAAAAD0lEQVR42mP8X8AwAgiABKBAv+vAXklAAAAAElFTkSuQmCC data-src=https:reader034vdocumentsmxreader034viewer20220505035f95acdfa2eb0a272c6b2955html5thumbnails10jpg width=140 height=200 divdiv
