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Get NY DOH-695 2009-2024

Ealth. This form is offered electronically for the express use of Health Care Facilities and Care Providers only. Violators will be prosecuted. Health Facilities and Care Providers are responsible for the secure use of this form maintaining compliance with Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Personal Privacy Protection Law, New York Public Officers Law, Article 6-A. The information contained on this form is confidential and intended for the use of qualifie.

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