Fillable authorization to disclose forms utah

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AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION By signing this form, you give any carrier identified on the cover sheet of this application the right to gather medical information about you and your dependents for whom you have legal authority to sign (e.g., a minor child). A carrier typically gathers both paper and electronic records. This information, for example, helps a carrier evaluate...
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authorization to disclose forms utah
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