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Get ExamWorks Clinical Solutions Authorization for Use or Disclosure of Protected Health Information Pursuant to HIPAA & Appointment of Representative

Act of 1996) I hereby authorize the use or disclosure of my Protected Health Information and other information as described below. I understand that this authorization is voluntary. Individual/Claimant: Individual/Claimant SSN: Individual/Claimant Address: Medicare/Health Insurance Claim Number (HICN) #: Date of Injury:.

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