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Get and Sign This Form is to Be Filled Out by a Customer If There is a Request to Release the Customers Protected Health Information PHI to a
Diagnosis name of illness or condition and Procedure treatment Medical Records excluding psychotherapy notes Doctor and Hospital Prior Authorization for treatment approvals Dental Vision Pharmacy Customer Service Medical Management Other I also approve the release of the following types of sensitive protected health information PHI by WPS Health Solutions check all boxes that apply to you All sensitive PHI includes all information listed below OR Just sensitive PHI related to the topics checked...
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