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Get Novant Health Authorization to Disclose Protected Health or Billing Information 2015-2024

address: (One patient per form) Date of birth: Last 4 numbers of SSN: Telephone: ( ) Although Novant Health will use reasonable means to protect the security and confidentiality of emails sent and received, we cannot guarantee the security and confidentiality of all email communications. Release Information From: Release Information To: (list applicable Facility(s) and/or Practice(s)) (Name of facility, person, company) (Relationship) (Street address or PO Box, City, State, Zip code) (P.

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