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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH …
www.dhcs.ca.gov• I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. • I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time.
RHEUMATOLOGY ASSOCIATES Main Phone: 214 …
arthdocs.comRHEUMATOLOGY ASSOCIATES Main Phone: 214-540-0700; Main Fax: 214-540-0701 PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION By signing this authorization, I authorize Rheumatology Associates to use and/or disclose certain