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AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Section A: Must be completed for all Authorizations By signing this Authorization, I hereby authorize and permit the use and/or
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Section A must be the first part of the form to be completed.
All individuals or entities subject to the reporting requirements must file section A.
Section A must be filled out by providing the requested information in the designated fields.
The purpose of section A is to gather essential information about the filer.
Information such as name, address, social security number, and other identifying details must be reported on section A.
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