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Authorization for Release of Protected HealthInformation PHI Authorization for Release of Protected HealthInformation PHI

Authorization for Release of Protected HealthInformation PHI Authorization for Release of Protected HealthInformation PHI

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Name of Patient s Representative Relationship to Patient Photo ID Verified AUTH. Date Event Purpose of disclosure Description of information to be used or disclosed Is this request for psychotherapy notes Yes then this is the only item you may request on this authorization. You must submit another authorization for other items below. No then you may check as many items below as you need. All PHI in medical record Operative Information Labor/delivery sum. Admission form Cath lab OB nursing...
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