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depts.washington.eduAUTH TO DISCLOSE/OBTAIN PHI UH0626 REV JAN 22 BACK By signing this page, I acknowledge that I have read and agree to the terms on both sides of this form. Patient Authorization to Disclose, Release or Obtain Protected Health Information. Minors: A minor patient’s signature is required in order to release the following information (1) conditions
Request to access, inspect, or obtain protected health ...
www.walgreens.comREQUEST TO ACCESS, INSPECT, OR OBTAIN PROTECTED HEALTH INFORMATION Request: I request to review health information held about me in the Walgreens “designated record set” in accordance with the Health Insurance Portability and Accountability Act of …