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Search results with tag "Authorization for use and"
DOC-1163A Authorization for Use and Disclosure of ...
doc.wi.govspecific protected health information authorized for use/ disclosure this authorization applies to medical, mental health, developmental disability and alcohol/drug abuse information, and hiv test results, unless excluded below. i do not want the following information disclosed.
Applicant Authorization for Use and Disclosure of Personal ...
www.merckhelps.comApplicant Authorization for Use and Disclosure of Personal Health Information I understand that in order for the Merck Patient Assistance Program, Inc. (Merck PAP) …
AUTHORIZATION FOR USE AND DISCLOSURE - portal.ct.gov
portal.ct.govThe Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. *** HIV Related Information: This information has been disclosed to you from records whose confidentiality