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Get HI HIPAA Authorization For Release Of Information_DSA

On is voluntary and made to confirm my directions. I understand that once the information is disclosed, it may be re-disclosed and no longer protected by federal privacy regulations. I hereby give permission for the disclosure of my personal health information in the manner described below. My Name: Address: Telephone: Member Number: Section B: Personal Health Information to Be Disclosed: I authorize the disclosure of the following personal health information: All medical information relevant.

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