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Patient Disclosure Authorization HIPAA
Patient Disclosure Authorization HIPAA


 
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List Price: $55.00
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Setup Cost: $0.00
Unit Qty: 50
Unit: pack
Overall Dimensions: 8-1/2 X 11


Product Code: DIS-100-DFS

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Protect your practice and avoid privacy disputes with this clear, step-by-step form authorizing release of patient information.

  • Personalization includes: Includes your imprinted practice name, address, and phone number, up to 5 lines. 2-part form provides a patient copy and a 2-hole punched permanent record.

Meets HIPAA Regulations


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