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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH
The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.
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Web Portal Quick Reference Guide
Easily search for Member details, including eligibility status, covered benefits and missed services information. Create, submit, correct and void claims;
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Important information about releasing patient medical records
Completing all sections of this form will facilitate timely release of your information. 1. PATIENT INFORMATION. Patient last name. First name. MI Date of
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