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 Healthplex Authorization Form Sample 2013

Healthplex Authorization Form Sample 2013

Use a Healthplex Authorization Form Sample 2013 template to make your document workflow more streamlined.

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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