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STATE OF OKLAHOMA Oklahoma Health Care Authority 4545 N. Lincoln Blvd. Suite 124 Oklahoma City OK 73105 405 522-7300 Authorization to Release Medicaid Records Client Name Client ID DOB 1. I authorize the OHCA to release the above individual s Medicaid information as described below. 2. I understand the information in my Medicaid record may include information relating to sexually transmitted disease acquired immunodeficiency syndrome AIDS or human immunodeficiency virus HIV. If I don t put a...
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