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Fill and Sign the Autorizacin Para Entregar Informacin F262 005 999 Autorizacin Para Entregar Informacin F262 005 999

Fill and Sign the Autorizacin Para Entregar Informacin F262 005 999 Autorizacin Para Entregar Informacin F262 005 999

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Devuelva el formulario completo a: Department Labor and Industries PO Box 44291 Olympia WA 9504 -4291 Autorización para entregar información Información del trabajador : Nombre del trabajador : Número de reclamo : Número de seguro social (para identificación solamente ): Fecha de nacimiento : Proveedor de la salud: Nombre del proveedor : Doy autorización para entregar a Labor e Industrias o a su representante cualquier información que tenga relacionada con mi(s) afección(es) mientras estuve bajo su tratamiento. Además de sus observaciones , por favor incluya: • Expedientes del historial médico. • Exámenes . • Consultas . • Informes de Rayos X • Análisis de laboratorio. • Informes de operaciones y de patología. • Hojas clínicas de los médicos y enfermeras . • Expedientes de hospitales . • Diagnósticos . • Información sobre medicamentos o tratamiento relacionado con cualquier enfermedad, lesión u otra afección física. Por favor entregue todos los expedientes de l tratamiento recibido por: La información que se debe entregar debe incluir : Abuso del alcohol Abuso de drogas SIDA (HIV) Tratamiento psiquiátrico Y/o cualquier otra información protegida por la ley federal. Entiendo que estoy autorizando la entrega de estos documentos para que Labor e Industrias pueda administrar y procesar mi reclamo. Entiendo que estos documentos se considerar

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How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device How to Sign a PDF on a Mobile Device

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How to Sign a PDF on iPhone How to Sign a PDF on iPhone

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How to Sign a PDF on Android How to Sign a PDF on Android

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