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Get Hipaa Compliant Authorization Form 2011

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164. 508 TO Name of Healthcare Provider/Physician/Facility/Medicare Contractor Street Address City State and Zip Code RE Patient Name Date of Birth Social Security Number I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record c.

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