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Directory Results for I hereby authorize Tiffin University to I hereby authorize VTS INVESTIGATIONS or any of its representatives to seek information for consideration of

I hereby authorize Tiffin University
I hereby authorize to act as
I hereby authorize to act as my
I hereby authorize to appeal my insurance carriers
I hereby authorize to charge my credit card
I hereby authorize to deduct $ from the first paycheck of each month on a pre-tax basis to be used for the purchase of a Transit Pass
I hereby authorize to deposit the reservations with my credit card as specified below:
I hereby authorize to disclose my health information to:
I hereby authorize to disclose my individually - unitedchurchhomes
I hereby authorize to disclose records obtained in
I hereby authorize to disclose the following information ...
I hereby authorize to forward my dental history, in accordance
I hereby authorize to have my direct deposit moved to my account with First Option Bank
I hereby authorize to initiate credit entries, and to initiate, if necessary, debit entries and
I hereby authorize to provide a copy, summary or a
I hereby authorize to receive any criminal
I hereby authorize to receive any criminal history record information pertaining to me that may be in the criminal justice files of the State of Georgia or local criminal justice agency in the State of Georgia
I hereby authorize to receive any Georgia
I hereby authorize to receive any Georgia criminal
I hereby authorize to receive my payroll deduction on ... - Foresters - marketing foresters
I HEREBY AUTHORIZE TO RELEASE
I hereby authorize to release information
I HEREBY AUTHORIZE TO RELEASE INFORMATION FROM MY (OR
I hereby authorize to release information from the record of
I hereby authorize to release medical information from the records of
I hereby authorize to release medical information from the records of:
I hereby authorize to release medical records
I hereby authorize to release medical, psychiatric,
I HEREBY AUTHORIZE TO RELEASE MY HEALTH
I hereby authorize To release my medical records to: NASHVILLE ENDOSCOPY CENTER 30020TH AVENUE NORTH 8TH FLOOR NASHVILLE, TN 37203 Patients name date of birth SSN Address Date last seen: Signature (parent, if minor) date
I hereby authorize to release my protected health information including copies of
I hereby authorize to release my protected health information to
I hereby authorize to RELEASE my protected health information to:
I hereby authorize to release personal health information on
I hereby authorize to release the
I hereby authorize to release the following information contained in its hospital records to:
I hereby authorize to release the protected health
I hereby authorize to release the requested
I hereby authorize to release to - Celebration Pediatrics
I hereby authorize to release to the - integritychiropractic
I hereby authorize to send credit entries, as well as make
I hereby authorize to use and/or disclose the protected health information described below to:
I hereby authorize to use or disclose the following - hancockmedical
I hereby authorize to use or disclose the following protected health information from the
I hereby authorize Total Payroll Services to provide payroll and pension data for our company to The Comprehensive Companies i
I hereby authorize Tow Pros Towing (TPT) to remove vehicles from our property located at
I hereby authorize Town of Middleton to initiate automatic deposits to my account at the financial institution named
I hereby authorize Town of Newfane Water/Sewer billing, to initiate debit entries or such adjusting
I hereby authorize Tracy Public Schools, their employees, agents, and camp volunteers to act for me according to their best ju
I hereby authorize Transition Family Services to (check applicable):
I hereby authorize Treasured Smiles Dentistry, LLC to release any medical/dental information as
I hereby authorize treatment, administration of anesthesia, surgical treatments for my minor
I hereby authorize Trinity College of the Bible and Theological Seminary, hereinafter - trinitysem
I hereby authorize TruAssure Insurance Company to charge/deduct the premium amount from the
I hereby authorize True Form Chiropractic and any of its appointed assistants to obtain the following information from the healthcare record of:
I hereby authorize Turner Farms Self Storage to charge the below referenced credit card for the AMOUNT AUTHORIZED
I hereby authorize Tyler 2 Construction to initiate credit entries or such adjusting entries which are necessary for corrections, to my checking account and depository indicated below
I hereby authorize Tyrrell County Schools, hereinafter called COMPANY, and The East Carolina Bank to
I hereby authorize U - markeysenategov
I hereby authorize UCM/Geller Center for Spiritual Development to initiate withdrawals from my account at - gellercenter
I hereby authorize UNDP to deduct from my monthly payroll the amount specified below and remit it to United Nations Federal Credit Union for the deposit into my account mentioned below
I hereby authorize Unified School District #252 to initiate credit entries to the following
I hereby authorize Unitarian Universalist Society:East, hereinafter called UUS:E, to initiate debit entries to my
I hereby authorize United Recyclers Group, LLC, hereinafter called URG, to initiate credit
I hereby authorize United States Fire Insurance Company or its ...
I hereby authorize UNITED TALENT LLC to initiate credit entries to my account identified below in the
I hereby authorize United Way of Northwest Illinois to deduct my contribution directly from my bank
I hereby authorize UnitedHealthcare, hereinafter, called COMPANY, to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my (our) checking/savings account(s) indicated below and the
I hereby authorize Unity Foundation of LaPorte County, Inc to draft ...
I hereby authorize Upper Cumberland Electric Membership Corporation to draft my bank account for the amount due on
I hereby authorize Urban Commercial Mortgage or any of its assignees to verify my credit history in
I hereby authorize US Pain & Spine Institute to release any information acquired in the course of my examination or treatment for the
I hereby authorize use and disclosure of the named ...
I hereby authorize use and disclosure of the named individuals health information as described below
I hereby authorize use of disclosure of the named individual\'s health information as described below
I HEREBY AUTHORIZE USE OR DISCLOSE MEDICAL RECORDS OF THE
I hereby authorize use or disclosure of protected health ...
I hereby authorize use or disclosure of protected health information about me as described below
I hereby authorize use or disclosure of the above named individual Health Information as described below
I hereby authorize use or disclosure of the named individual s health information
I hereby authorize use or disclosure of the named individual's health ...
I hereby authorize use or disclosure of the named individuals health information
I hereby authorize use or disclosure of the named individuals health information as described below
I hereby authorize use or disclosure of the named individual\'s health information as described below:
I hereby authorize Valero Energy Corporation andor its subsidiaries to initiate automatic deposits to my account at
I hereby authorize Valley Children's Hospital to use and disclose a ...
I hereby authorize Valley Children\'s Medical Group to request and receive a copy of the specified health information
I hereby authorize Value Specialty Pharmacy to bill my insurance carrier or any other payment source
I hereby authorize Vector Risk Solutions to initiate automatic deposits to my account at the financial
I hereby authorize Velocity Vehicle Group (VVG) to use my photo or any likeness of me on VVGs website, Facebook page, advertisements, digital postings, or brochures
I hereby authorize VERBAL disclosure of the named individuals health information as described below
I hereby authorize Verde Valley Employee Benefit Pool to automatically deposit my flexible - apehp
I hereby authorize Verity Screening Solutions, 6834 S
I hereby authorize Vermilion Physical Therapy to use or disclose the following protected health information (PHI) from the
I hereby authorize Village Fuel Stop, Inc
I hereby authorize Vincent Ortolano, M
I hereby authorize Virginia Heller, DC and Triple H Chiropractic, LLC and its providers
I hereby authorize Virginia Premier Health Plan, Inc
I hereby authorize Visiting Nursing Association of Central Jersey Community Health Center, Inc
I hereby authorize VTS INVESTIGATIONS or any of its representatives to seek information for consideration of