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AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Patient Name:Phone #:Date of Birth: PCP:I hereby authorize: Erie Family Health Centers, Health Information Department, 2750 W North Avenue, Chicago,
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01
Write your full name in the space provided for 'Print Name'.
02
Sign your name in the space provided for 'Signature'.
03
Date the form in the space provided for 'Date'.
04
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Who needs i hereby authorize erie?
01
Individuals who want to give authorization to Erie for specific actions or transactions.
02
Legal representatives or agents acting on behalf of someone else.
03
Employees or contractors of Erie who require authorization for certain tasks.
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What is i hereby authorize erie?
i hereby authorize erie is a form that grants permission or consent for Erie to perform certain actions on behalf of the individual.
Who is required to file i hereby authorize erie?
Individuals who wish Erie to act on their behalf or perform specific tasks are required to fill out and submit the i hereby authorize erie form.
How to fill out i hereby authorize erie?
To complete the i hereby authorize erie form, individuals should provide their personal information, specify the actions they are authorizing Erie to take, and sign the document.
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The purpose of i hereby authorize erie is to formally grant permission to Erie to carry out certain tasks or actions on behalf of the individual who is submitting the form.
What information must be reported on i hereby authorize erie?
The i hereby authorize erie form typically requires personal information of the individual, details of the actions being authorized, and the signature of the individual.
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