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Directory Results for PATIENT AUTHORIZATION DISCLOSURE OR RECEIPT OF PROTECTED HEALTH INATION Name of Patient Date of Birth Patient Address Phone # SS#* *Providing your SS# is voluntary, but necessary to accurately identify your medical records to Patient Authorization Entira - eHX 5-15 2.docx

PATIENT AUTHORIZATION DISCLOSURE OR RECEIPT OF PROTECTED HEALTH INATION Name of Patient Date of Birth Patient Address Phone # SS#* *Providing your SS# is voluntary, but necessary to accurately identify your medical records
PATIENT AUTHORIZATION doc
Patient Authorization Entira - eHX 5-15 2.docx