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Hipaa Waiver -Form Fill
Section One
Q1
Date
Date
Q2
Name of Patient
First Name
Q3
Name of Patient
Last Name
Q4
Date of Birth
Date
Q5
Age
Q6
Type of Health Records to be Disclosed
Q7
Period of Allowed Heath Records Disclosure
Q8
Purpose of Authorization
Q9
This Authorization Expires
Q10
Signature of Patient
Q11
Reason
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