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Get Sedgwick Form 39 2011

At my personal health information may be released to others in accordance with the terms of this release and I have a right to receive a copy of this information. I understand that if a recipient of the health information is not governed by federal and state confidentiality laws, the health information disclosed as a result of this authorization may be re-disclosed by the recipient and is no Claim Nbr (Mandatory): ____________ longer protected by the Privacy Rule of the Health Insurance Porta.

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