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AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION (PHI) Administered by Denver Health Medicaid ChoiceSECTION A: MEMBER INFORMATION Complete all information requested in this section for
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To fill out section a member information, follow these steps:
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Begin by entering the member's full name in the designated field.
03
Provide the member's date of birth.
04
Specify the member's gender.
05
Enter the member's contact information, including their phone number and email address.
06
If applicable, provide the member's address details, such as their street, city, state, and ZIP code.
07
Include any relevant additional information about the member, such as their occupation or relationship to the primary account holder.

Who needs section a member information?

01
Section a member information is needed by organizations, institutions, or individuals who are collecting data or managing memberships.
02
This information is often required in various contexts, such as membership applications, registration forms, or customer databases.
03
By collecting and organizing member information, organizations can maintain accurate records, effectively communicate with members, and provide personalized services.
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Section A member information refers to the details of individuals who are part of a specific group or organization.
Any individual or entity responsible for the group or organization that requires the filing of section A member information.
Section A member information can be filled out by providing the necessary details of each member, such as their name, contact information, and role within the group.
The purpose of section A member information is to maintain a record of individuals who are associated with a particular group or organization for reference and identification.
The information that must be reported on section A member information typically includes the full name, address, contact details, and position of each member.
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