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Illinois Permiso para divulgar información de facturación de salud - Permission To Disclose Health Billing Information

State:
Multi-State
Control #:
US-PRM-26
Format:
Word
Instant download

Description

Formulario de firmas individuales que otorgan permiso para que el proveedor de atención médica divulgue información médica a las personas incluidas en la lista. Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.

How to fill out Illinois Permiso Para Divulgar Información De Facturación De Salud?

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Illinois Permiso para divulgar información de facturación de salud