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Directory Results for PATIENT AUTHORIZATION TO DISCLOSE, RELEASE AND/OR OBTAIN PROTECTED HEALTH INATION to Patient Authorization to Disclose, Release or Obtain Protected Health Ination Patient Name: Date of Birth: Telephone #: Purpose of Disclosure: Attorney Insurance Provider OR: Other (specify) INFORMATION TO BE RELEASED TO: INFORMATION TO

PATIENT AUTHORIZATION TO DISCLOSE, RELEASE AND/OR OBTAIN PROTECTED HEALTH INATION
Patient Authorization to Disclose, Release andor Obtain Protected Health Ination - depts washington
Patient Authorization to Disclose, Release or Obtain Protected Health Ination Patient Name: Date of Birth: Telephone #: Purpose of Disclosure: Attorney Insurance Provider OR: Other (specify) INFORMATION TO BE RELEASED TO: INFORMATION TO