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AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION SECTION A: Member Information (Please Print) Members Name: Address: Member Identification Number: Date of Birth: Group or Account # on ID card: Phone

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What is section a member information?

Section A member information refers to the details of individuals who are part of a specific section or group.

Who is required to file section a member information?

Individuals or entities who are members of the specific section or group are required to file section A member information.

How to fill out section a member information?

Section A member information can be filled out by providing the required personal details of each member in the designated fields.

What is the purpose of section a member information?

The purpose of section A member information is to maintain accurate records of individuals within a specific section or group.

What information must be reported on section a member information?

Section A member information typically includes the full name, contact details, and relevant identification information of each member.

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