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Get HIPAA Designated Contact Form - Anthem

Ed health information (PHI). Notes: This form must be completed by someone with proper authority within your organization (for example, the Privacy Officer). We require names, not merely job titles, of individuals who may receive PHI. Please complete a new form whenever there is a change to the Designated Contact Person list. ADDITION of contact person CHANGE / DELETION of contact person (please indicate next to name) Producer/Broker Contacts (see below) Check this box if your g.

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