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Get and Sign Mail or Fax to Release of Information, 8101 W Sam

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Authorizations - Required Patient Name Date of Birth Provider s Name Recipient s Name Patient s Phone Last 4 digit SSN optional Address 1 Provider s Address 2626 Capital Medical Blvd. 4. If the requester or receiver is not a health plan or health care provider the released information may no longer be protected by federal privacy regulations and may be re-disclosed. 6. I may refuse to sign this authorization and that it is strictly voluntary. 2. My treatment payment enrollment or eligibility...
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