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Form Information Healthcare Request for Restriction of Use and Disclosure of Private Health Information THIS FORM WILL ALLOW ME, AS A CHINA HEALTHCARE* MEMBER/PARTICIPANT, TO REQUEST A RESTRICTION

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This form allows individuals or businesses to report and provide information about a specific subject.

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The individuals or businesses who are required to file this form will depend on the specific requirements set by the governing authority.

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The purpose of this form is to collect and document required information, reports, or data related to a specific subject, as mandated by the governing authority.

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