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ACCOUNT # DATE PATIENT'SFIRST NAME LAST NAME MI  Form

ACCOUNT # DATE PATIENT'SFIRST NAME LAST NAME MI Form

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Accountability Act of 1996 HIPAA I have certain rights to privacy regarding my protected health information PHI. Health Questionnaire YES Past Medical History NO Patient denies any past medical history Acid Reflux ADD / ADHD Anemia Anxiety Arthritis Asthma Atrial fibrillation / irregular heartbeat Bipolar disorder Bleeding disorder Blood transfusion BPH enlarged prostate Breast cancer Celiac disease Clotting disorder Chemotherapy or radiation treatments Colon cancer COPD / Emphysema Crohn s...
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