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Get OCA Official Form 930 NYHIPAA 2009

Tion HIV-Related Information Authorization to Discuss Health Information (b) By initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney, or a governmental agency, listed here: (Attorney/Firm Name or Governmental Agency Name) 10. Reason for release of information: At request of individual Other: 12. If not the patient, name of person signing form: 11. Date or event on which this authorization will expire: 13. Authority.

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