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AUTHORIZATION TO RELEASE MEDICAL INFORMATION Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested may invalidate
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- Legal entities involved in contracts or agreements with the organization
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The name of the provider organization refers to the official name of the entity providing services or products.
The entity responsible for providing the services or products is required to file the name of the provider organization.
The name of the provider organization can be filled out on official forms or documents using the full legal name of the entity.
The purpose of providing the name of the provider organization is to clearly identify the entity responsible for the services or products.
The name of the provider organization should include the legal entity name, any trade names, and any DBA (doing business as) names.
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