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Get Northwest Audiology & Hearing Aid Center Patient Authorization For Use & Disclosure Of Protected

Ion, I , authorize the release my confidential health information through the release of a copy of my designated medical record or a summary or narrative of my designated medical record containing protected health information (PHI), to the person(s) or entity listed below: Patient Name: Patient Date of Birth: Patient Social Security No.: Patient Driver s License No. (include state) Patient Address: Patient Address cont..

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