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Get HIPAA PRIVACY REVOCATION OF AUTHORIZATION - Hirsp

The HIRSP Authority as a covered entity, to implement processes that give policyholders certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Completing this form is voluntary. However, if you would like an accounting of the disclosures that HIRSP or our business associates have made of your protected health information, you must provide all of the information requested on this form.

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