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New Patient Packet

WEBThat the recipient of the protected health information under this authorization should not re-disclose the information without a written authorization. Health Care Provider will not …

Actived: 8 days ago

URL: https://secure.highlandwebforms.com/forms/18146/18840/P48P/form.html

Pregnant Patient Package

WEBI have read and understand the ultrasound statement of Northland Women’s Health Care, PC. Patient Signature * – Draw your signature below using a tablet, mouse or …

Category: Health Go Health

Birth Defects Risk Assessment

WEBI have read all of the above questions carefully, and understand that this information is important for my health care providers to determine if my baby could be at an increased …

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Authorization for Release of Health Information

WEBMedical Records Release. Patient’s Full Name. Former Name (s) (where applicable) Soc. Sec. No. Date of Birth. Phone. Fax. I, or my personal representative, hereby authorize …

Category: Medical Go Health

Authorization to Release Health Information

WEBAuthorization to Release Health Information. * = required fields. Please be aware that there is a charge per page of medical records given directly to the patient. Please allow 5-10 …

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Receipt of Privacy Notice

WEBPermission to Disclose Protected Health Information . I give Independence Women's Clinic permission to disclose my protected health information to the following individuals …

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