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Get HIPAA Compliant Authorization for Release of Medical Information

this authorization is voluntary. I understand that the released information may be subject to redisclosure by the recipients and no longer be protected by federal privacy regulations. Patient Name: Date of Birth: Persons/organizations authorized to provide the information: TRISTAR Risk Management, P.O. Box 2805, Clinton, IA, 52733 is authorized to receive and use/redisclose the information in connection with my claim for worker’s compensation benefits. I further authorize that a photocopy .

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