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Healthplex Authorization Form Sample 2013
Described below to be provided to or obtained by the following:
Name of Individual/Facility/Company to Receive PHI
Name of Individual/Facility to Disclose PHI:
___________NORMAN REGIONAL HEALTH SYSTEM__
___________ATTN: HEALTH INFORMATION_________
Address: ________________________________________
Address: ___901 NORTH PORTER__________________
City, State: _______________________________________
City, State: __NORMAN OK 73071___________________
Dates of treatment to be released:...
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