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  • HIPPA Disclosure List

    Загружено:

    Leah Doherty
    7 просмотров2 страницы
    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

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    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

    Авторское право:

    Attribution Non-Commercial (BY-NC)
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    7 просмотров2 страницы

    HIPPA Disclosure List

    Загружено:

    Leah Doherty
    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

    Авторское право:

    Attribution Non-Commercial (BY-NC)
    Скачайте в формате DOCX, PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 2

    HIPAA Disclosure Doctor/Clinic List

    Patient Name: _______________________ D.O.B. __________ Phone:__________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

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