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 AUTHORIZATION for RELEASE of PHI UCLA Health Uclahealth 2019

AUTHORIZATION for RELEASE of PHI UCLA Health Uclahealth 2019

Use a AUTHORIZATION FOR RELEASE OF PHI UCLA Health Uclahealth 2019 template to make your document workflow more streamlined.

Signature of Patient / Legal Representative Printed Name Phone Number Include Area Code If signed by someone other than the patient indicate relationship to the patient Signature of Witness/ Interpreter only if patient unable to sign UCLA HIMS Release of Information 10833 Le Conte Ave CHS BH225 Los Angeles CA. MY RIGHTS I understand this authorization is voluntary. Treatment payment enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the...
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