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Authorized Representative Form This form is used to confirm a Patient/Parents permission that the Health Plan/Provider may discuss or disclose their Protected Health Information (PHI) to a particular
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The authorized representative is a designated individual who has the legal authority to act on behalf of an entity or individual in certain matters.
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Details such as the name, contact information, and legal authority of the authorized representative, as well as information about the entity or individual being represented, may need to be reported.
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