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AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA
Submit HIPAA Authorization Form
Patient Name
(Required)
Last Name
Phone Number
(Required)
Email
(Required)
Date of Birth
(Required)
Address
(Required)
Address Line 1
Address Line 2
City
State
Zip / Postal Code
Insurance Company Info
(Required)
Upload Cover Letter
(Required)
Scan Copy of HIPPA Authorization Form with Duly Signed
(Required)
Submit