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Get Dshs Authorized Representative Form

HO SB Sponsor paying premiums. Sponsors name and address sent to Office of Financial Recovery. NA Client Authorization AUTHORIZED BY CLIENT SIGNATURE DATE SIGNED PRINT NAME NOTE HIPAA restrictions prevent us from discussing the client s individual health information with the authorized representative unless the representative has power of attorney for the client or the client has signed a DSHS 14-012 Consent form. This includes disclosure of ment.

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