Hipaa Medical Authorization Form Page 2

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Hipaa Medical Authorization Form Printable pdf

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I have carefully read and understand the above, and do herein expressly and voluntarily authorize the

disclosure of the above information to those persons or agencies listed above.

Date: _____________________________

Patient or Patient Representative:

_________________________________________________________

(Signature)

This authorization is designed to be in compliance with the Health Insurance Portability and

Accountability Act (“HIPAA”) 45 CFR Parts 160 and 164.

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