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Please Fill Out Both Sides of This Form and Bring it with You 2018-2023
Any necessary precertification prior to your appointment. In the event there is a breach of security which involves your health information you will be notified per HIPAA regulations. You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at https //ocrportal.hhs. gov/ocr/portal/lobby. jsf or by mail or phone at U.S. Department of Health and Human...
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