Get the free (optional): Address 1: Address 2: City: State: Zip: This authorization will expire o...
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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI) Section A: This section must be completed for all Authorizations Patient×Plan Member Name: Birth Date: Provider s×Health Plan s Name:
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How to fill out optional address 1 address
How to fill out optional address 1 address:
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Find the appropriate field for "Optional Address 1 Address" on the form you are filling out.
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