Get the free At my request, I give Essentia Health permission to VERBALLY discuss the following m...
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X Signature patient/parent of Minor or personal representative Date AUT001 Protected Health Information EH10302 1/17 AUTH. Extent that the program or person which is to make the disclosure has already acted in reliance on it. In reliance upon this request. I understand I must notify Essentia Health in writing if I want to revoke my permission. longer be protected by Federal privacy regulations. What if I change my mind You can change or revoke stop this process at any time by notifying us in...
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