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Seq. and section 39- 71- 604 MCA that are directly relevant to the claimed injury disease or death. POLICYHOLDER NAME DOB RELATION INSURANCE COMPANY ID/CLAIM GROUP PLEASE READ - - IMPORTANT INFORMATION 1. I understand that signing this form authorizes the release to the workers compensation insurer or its agent rehabilitation records Social Security records and health care information medical records pursuant to HIPAA Public Law 104- 191 42 USC section 1301 et. To 45 of the balance...

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