33200 DEQUINDRE RD, SUITE 200
STERLING HEIGHTS, MICHIGHAN 48310
P: (586)9770200 - FAX (586)9770000
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HIPPA RELEASE
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PATIENT REGISTRATION
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PATIENT HISTORY
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Insurance Auth
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ACKNOWL EDGEMENT
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HIPPA RELEASE
Patient's Name
Patient's Name
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Ii authorize the release of information including diagnosis, records, examination rendered to me and claims information. This information may be released to:
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Please check all that apply: name(s)
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Information is not to be released to anyone.
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