Get Florida Medicaid Authorization For The Use And Disclosure Of Protected Health Information 2012 2012
Umber Disclosure of your Social Security Number is not mandatory for purposes of completing this form. However, the Agency for Health Care Administration may request your Social Security Number pursuant to Section 119.071, Florida Statutes. Should you choose to provide your Social Security Number as requested, the Agency shall use your information for purposes of finding the requested information. Phone Date of Birth Medicaid ID Number or Gold Card Number Street Address City State Zip Code I a.
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