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OTHER
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Directory Results for AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INATION AND OTHER RECORDS NAME: DOB: SSN: I HEREBY GRANT PERMISSION TO AND AUTHORIZE THE USE OR DISCLOSURE OF THE ABOVE NAMED INDIVIDUALS RECORDS AS DESCRIBED BELOW TO THESE to Authorization for Use and Disclosure of Protected Health Ination Form

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INATION AND OTHER RECORDS NAME: DOB: SSN: I HEREBY GRANT PERMISSION TO AND AUTHORIZE THE USE OR DISCLOSURE OF THE ABOVE NAMED INDIVIDUALS RECORDS AS DESCRIBED BELOW TO THESE
Authorization for use and disclosure of Protected Health Ination for clinic and field records
Authorization for Use and Disclosure of Protected Health Ination Form