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AUTHORIZATION FOR RELEASE OF MEDICAID PROTECTED INFORMATION FROM THE NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS TO A THIRD PARTY OTHER THAN A MEDICAID ENROLLEE/PATIENT Enrollee/Client Name Date of Birth Client Identification Number CIN By signing this form I understand that I am allowing the New York State Department of Health to use or disclose all of my payment information as indicated below. This may include data o.

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