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Authority for Release of Medical Information

Medical Information Authorization Without In Alameda

Category:

Releases and Waivers - Medical

State:

Multi-State

County:

Alameda

Control #:

US-00426

Format:

Instant download

Description

Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.

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Please completely fill in ALL areas to include the following: • Patient Information: Patient Name, Patient Date of Birth and Phone. Number. Authorization Submission.The Alliance Prior Authorization (PA) Request Form is used for all services requiring prior authorization from the Alliance. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:. Please add a cover letter with your name, phone number, email and your organization or facility's name and fax the form to (510) 244-0596. Blank Application Forms. The below forms may be dropped at a secure drop box, at one of our offices, during regular business hours, am to pm.

Medical Information Authorization Without In Alameda

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