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louisiana department of health form hipaa 402p

Get the free louisiana department of health form hipaa 402p 2013-2020

Documentation on the above Personal Representative has been obtained. Signature and Title of Agency Representative HIPAA 402P Page 1 of 2 Issued 4/14/03 Revised 09/17/2013 Important Information about Authorization We may need your authorization to use disclose or obtain your health information for some of our services. Authorization to Release or Obtain Health Information including paper oral and electronic information Request Date Name Mailing Address Date of Birth City/State/Zip Medicaid or...
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