Map 751e 2025

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The document is an authorization form allowing the release of medical information regarding a disabled person to the Medical Assistance Program for public health insurance application purposes. It includes details about the disabled person, their relationship to the source, and specifies the types of medical records and information that can be disclosed. The authorization can be revoked at any time and will automatically end after relevant proceedings related to Medicaid.

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2012	4.8 Satisfied (161 Votes)

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