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1309 R10/2013 AUTHORIZATION FOR THE DISCLOSURE OF PROTECTED HEALTH INFORMATION Gundersen Lutheran Medical Center Inc. Gundersen Clinic Ltd. 1. Patient Name Maiden/Former Name Date of Birth La Crosse WI 54601 Address 1900 South Avenue AVS-001 La Crosse WI 54601 PHONE 800 362-9567 Ext. Patient Name Medical Record Number Contact Serial Number HAR COMMUNICATION OF HEALTH INFORMATION With the implementation of the Health Insurance Portability and Accountability Act HIPAA Gundersen Clinic Ltd. File...
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What is maidenformer name?
Maidenformer name is the name previously used by an individual before getting married or changing names.
Who is required to file maidenformer name?
Individuals who have changed their name due to marriage or other reasons are required to file their maidenformer name.
How to fill out maidenformer name?
To fill out maidenformer name, individuals can typically use a form provided by the relevant government agency or update their information online.
What is the purpose of maidenformer name?
The purpose of maidenformer name is to keep a record of an individual's previous name for identification and documentation purposes.
What information must be reported on maidenformer name?
The maidenformer name typically requires reporting the individual's current legal name and the name previously used.
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