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Get Fidelis Care HIPAA Privacy Release Form

Name: ____________________________________ Member ID: __________________________________ Birthdate: ________ /________ / ________ 1. Authorization a. I authorize Fidelis Care New York to use and disclose the protected health information described below to __________________________________________________ (individual seeking the information). Authorization to discuss health care information: By initialing here _________ I authorize Fidelis Care to discuss my health information with the en.

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