Fillable PHI - Family Practice of Grand Island, PC

Family Practice of Grand Island, PC 12/12/05 2116 W Faidley Ave, Ste 400 Grand Island, NE 68803 Phone 3083810162 Fax 3083894445 AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION (PHI) (Please complete in ink. Attach copy of ID for verification.) Patient Name Previous Name Date of Birth SS # Acct # I give written authorization for verbal &/or written PHI disclosure on the patient named above: FROM:...
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