Des moines university clinic health information management dept. 3200 grand ave., des moines, ia 50312 phone (515) 271-7836 fax (515) 271-1726 authorization to release medical information the medical records of: (patient name) name: address: date...
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Department of health services county of los angeles authorization for use and disclosure of protected health information last name first hereby authorizes: lac+usc medical center harbor-ucla medical center: king drew medical center olive view...
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System authorization access request (saar)privacy act statementauthority:executive order 10450, 9397; and public law 99-474, the computer fraud and abuse act.principal purpose: to record names, signatures, and other identifiers for the purpose of...
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Medical record request please fill out the form completely. fax or mail release to: medical records release 550 landmark ave bloomington, in 47403 phone: 8123556961 fax: 8123553269 patient name: (please print) last name first name social security...
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Po box 7434 jackson, wy (307) 733-3900 phone (307) 739-7683 fax request for release of medical records: i, request (patient name if not self) patient birthdate, ? medical records ? x-rays ? mri ? other to be sent to: (include e-mail address if you...
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Hipaa compliant authorization for the release of patient information pursuant to 45 cfr 164.508 to: name of healthcare provider/physician/facility/medical contractor street address city. state and lip code re: patient name: date of birth: social...
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Donald c. sheridan, m.d. 10213 n. 92nd street, suite 101 scottsdale, az 85258 phone: (480) 8606005 fax: (480) 8601882 patient name: dob: medical records request fee the office of donald c. sheridan, m.d., p.c., will provide your records to you...
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Subject: hedis 2011 data collection for unitedhealthcare and affiliated commercial, medicare and medicaid/chip plans (see enclosed faq for additional membership and plan information) dear physicians and health care professionals: we value our...
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Minnesota epilepsy group, p.a. 225 smith avenue north, suite 201, st. paul, mn 55102 phone: (651) 2415290 fax: (651) 2415248 authorization for the use and disclosure of protected health information patient name (last first middle) previous last...
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The christ hospital orthopaedic associates date: first name: ssn: address: marital status: primary care physician name: guarantor name: address: emergency contact name: insurance primary: address: secondary: address: phone #: city/state: zip:...
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Suntm snmp management agent administration guide for sun supported servers version 1.6 at a minimum sun microsystems, inc. .sun.com part no. 820-5965-10 december 2008, revision a submit comments about this document at:...
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The pediatric center pc 126 morgan street stamford, ct 06905 hipaa authorization for release of patient records patient/patients name: i, , hereby authorize the pediatric center pc to release the medical health records: (please check one) copy of...
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Consent to release ferpaprotected student information (note: this consent does not cover medical records held solely by the college health center or the counseling center contact those offices for consent forms.) to: (name of college official and...
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Dermatology practice of the carolinas, p.a. 12611 n community house rd ste 102 charlotte, nc 28277 7045448200 7045448300 (f) catherine j pointon, md katherine joseph, pac consent for medical records release i request a copy of the following...
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Authorization to release confidential information patient s name i authorize and/or , and/or (name of hmo) (name of bho) the following person/agency/group: provider/agency/group address city state zip to disclose information and records regarding...
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