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About This Form
This form will allow you to review the Patient Authorization Form and provide your authorization with an electronic signature. Please fill out the information below to get started. The information you provide will be used by CareMetx, LLC, our affiliates, and our service providers, for your registration and participation in this program. Our Privacy Policy further governs the use of the information you provide. By providing the information and selecting the Next button, you indicate that you read, understand, and agree to these terms.