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Get DOC-1163A Authorization For Use And Disclosure Of Protected Health Information (PHI) (2)

Hat this will reveal that I am in a mental health or AODA treatment facility. PURPOSE OR NEED FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (check applicable category) Ongoing health care/treatment Review by patient Coordination of care or eligibility for services/benefits. Legal representation/proceedings (Court/Administrative) Review by family member/friend. Other Continued PATIENT NAME DOC NUMBER PATIENT RIGHTS Right to Receive Copy of This Authorization. Patients have a right to rec.

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