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Delaware HIPAA Medical Release Form

Delaware HIPAA Medical Release Form

Use a Delaware HIPAA Medical Release Form 0 template to make your document workflow more streamlined.

Part 7 Certification and Acknowledgement I certify that I am the person or the personal representative of the person designated in Part 1. I agree that my individually identifiable health information described in Part 3 and held by the person or entity listed in Part 2 may be disclosed to the person or entity listed in Part 4 for the purpose s designated in Part 5. Jane Doe ABC Laboratories XYZ Hospital etc. If you need to list more than one health care provider please provide an extra page...
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