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Get Wageworks GEN 7003.2 (WW-6949-HIPAA-PPT-AUTH) 2010

Alth Information (PHI) Participant Name Mailing address City, State, Zip Code Telephone Social Security # or Your Participant ID # as assigned by WageWorks Section B The Use and/or Disclosure Being Authorized PHI to be used and/or disclosed: Specifically describe the PHI to be used and/or disclosed. Check if this authorization is for psychotherapy notes. If this authorization is for psychotherapy notes, you must NOT use it as an authorization for any other type of PHI. Entities or Person.

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