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 Form HLTH5551 'Consent for Release of Pharmanet Patient 2020-2023

Form HLTH5551 'Consent for Release of Pharmanet Patient 2020-2023

Use a release pharmanet patient 2020 template to make your document workflow more streamlined.

Information intended only for PharmaNet Profiles Services. Any other distribution copying or disclosure is strictly prohibited. If you have received this fax in error please write MISDIRECTED across the front of the form and fax to 1-250-953-0432 then destroy the pages received in error. CONSENT FOR RELEASE OF PHARMANET PATIENT RECORD PATIENT INFORMATION Last Name First Name Personal Health Number PHN Middle Name Date of Birth MM/DD/YYYY PATIENT REPRESENTATIVE INFORMATION If authorization is...
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