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Below is a copy of your executed Release and Indemnification for Personal Protective Equipment:
Release and Indemnification for Personal Protective Equipment (the “Release”)
|*LEGAL*|
Name of Individual or Entity Responsible under the Release (e.g., a physician, a practice, a CMS, etc.) (the "Recipient"): |*AgreementIndividualOrEntity*|
Address provided on the Release: |*AgreementAddress*|
Signature of Recipient or Authorized Representative of Recipient: |*AgreementRepresentitiveSignature*|
Signature Date: |*AgreementDate*|
[Accepted] By checking this box, you consent to the terms of this Release and you agree to sign the document electronically. You agree that your electronic signature has the same legal validity and effect as your handwritten signature on the document, and that it has the same meaning as your handwritten signature.
Last Updated On
November 30, 2020
Originally Published On
August 11, 2020