Job and Family Service Blank Form 06723 2017-2023

Name: Ohio Authorized Representative Form - Fill Out and Sign Printable PDF Template | signNow
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Use a ohio authorized representative form 2017 template to make your document workflow more streamlined.

Care plans are authorized to disclose my protected health I understand PHI can include the following types of information and authorize its disclosure medical records substance abuse care vision care reproductive care mental health communicable disease pharmacy HIV/AIDS dental records and psychiatric care. Ohio Department of Medicaid Designation of Authorized Representative Section 1 Please Print Name of Applicant/Recipient Medicaid Billing Number or SSN County Street Address include Apt City...

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2014 OH ODM 06723 [2014-07] 2017

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