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Get MO HIPAA Privacy Authorization

Nce Portability and Accountability Act ---- 45 CFR Parts 160 and 164) 1. I hereby authorize all medical service sources and health care providers to use and/or disclose the protected health information (‘‘PHI’’) described below to my agent identified in my durable power of attorney for health care named __________________________________________________________________. 2. Authorization for release of PHI covering the period of health care (check one) a. from (date) _________________ - t.

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