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Revoke this authorization I must do so in writing and present my written revocation to the Health Information Management Department. Page 1 of 2 HIPAA FORM 3 Poplar Bluff Ob-Gyn AUTHORIZATION FOR RELEASE USE AND DISCLOSURE OF HEALTH INFORMATION Patient Name Date of Birth Address Phone Number Fax Number Access Request to Copy/Inspect I authorize the use/disclosure of health information about me as described below The following organization is authorized to make the disclosure Cardiovascular...
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