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to provision of treatment, payment and health care operations (TPO). This form and its contents are permissible under HIPAA. HIPAA does not restrict the communication of PHI to providers for TPO-related purposes. Patient Information Prescriber Information Patient Name: Prescriber Name: Date of Birth: Plan Participant ID Number: Prescriber Phone Number: Prescriber Fax Number: Exceptions may be allowed if considered medically necessary and meet one of the following circumstances: 1. There .

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