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Get Wyoming Hippa From Form

164) 1. I hereby authorize the disclosure by the Employees Group Insurance of protected health information to . Name of Individual 2. The Release of Information will remain in effect until terminated by me in writing. 3. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authoriza.

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