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Get Authorization To Disclose Health Information Form - Illinicare

Authorization to Disclose Health Information Notice to Member Completing this form will allow IlliniCare to share your health information with the person or group that you identify below. Keep a copy of all completed forms that you send to us. IlliniCare can send you copies if you need them. Fill in all the information on this form. When finished mail it to the address at the bottom of the page. If you are the Member s personal representative de.

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