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Get Blank Hipaa Authorization Form

Signature and Title of Agency Representative Date HIPAA 404P Page 1 of 2 Issued 4/14/03 Revised 09/17/2013 Important Information about Authorization We may need your authorization to use, disclose or obtain your health information for some of our services. You do not have to sign this form. If you agree to sign this authorization to release or obtain information, you will be given a signed copy of the form. A separate signed authorization form is r.

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