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Get and Sign HIPAA Privacy Rule Authorization  Form

Get and Sign HIPAA Privacy Rule Authorization Form

Use a legacy health information template to make your document workflow more streamlined.

Name Nickname/Maiden Name Birth Date Middle Name Telephone: Okay to leave detailed message?  Yes  No Patient’s Mailing Address Health Care Provider to Release Information: Name Person or Agency to Receive Information: Name Legacy Transplant Services Address Address 1130 NW 22nd Ave Suite 400 City Phone State Fax Zip City State Zip Portland OR 97210 Phone Fax (503) 413-6555 (503) 413-6563 kidney transplant evaluation Purpose of release:...
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