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Get Vha Handbook 120005 Form

Date of Birth: SSN: I hereby request and authorize the disclosure of all protected medical information for the purpose of review and evaluation in connection with a legal claim. I expressly request that all covered entities under HIPAA identified above disclose full and complete protected medical information spanning the time period of to including the following: All medical records, including inpatient, outpatient and emergency room treatment, all clinical.

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