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Get Rex Healthcare Authorization for Release of Information

Rex Healthcare 4420 Lake Boone Trail Raleigh NC 27607 919-784-3158 Fax 919-784-3343 AUTHORIZATION FOR RELEASE OF INFORMATION WORKERS COMPENSATION I authorize To use or disclose PHI to the following employer and/or their affiliated workers compensation case manager and/or their insurance company Employer Name Address Phone the protected health information of Patient City State Zip Attention Date of Birth / SS Telephone MR Description of informati.

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