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Get and Sign Federal and State Law, Including the Health Insurance Portability and Accountability Act  Form

Get and Sign Federal and State Law, Including the Health Insurance Portability and Accountability Act Form

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Billing and management services for affiliated or contracted healthcare providers who provide acute medical services. I sign this Authorization under penalty of perjury and attest that the information contained in this Authorization is true and correct and may be relied upon by US Acute Care Solutions. Patient Name First Middle Initial Last Name Title Sr. Jr. III. Date of Birth Telephone Number Street Address City State ZIP Last 4 digits of Social Security Number Section B Name of Individual /...
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