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For Office Use Only Leave on File Medical Records Request Authorization to Use and Disclose Protected Health Information PATIENT Name: Date of Birth: Current Address: City: State: Phone Number: (Zip:)
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Who needs for office use only?

01
Office personnel responsible for maintaining records.
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Administrative staff involved in internal office processes.
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Authorities or individuals who must review internal office use forms.
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Auditors and compliance officers ensuring proper usage of office resources.
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Managers or supervisors overseeing office operations.

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