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Get LA HIPAA 402P 2013

above Personal Representative has been obtained. ____________________________________________________________ Signature and Title of Agency Representative _____________________________ Date HIPAA 402P Page 1 of 2 Issued 4/14/03 Revised 09/17/2013 Important Information about Authorization We may need your authorization to use, disclose or obtain your health information for some of our services. You do not have to sign this form. If you agree to sign this authorization to release or obtain i.

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