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.
Medical Authorization Form Ct In Kings
Category:
State:
Multi-State
County:
Kings
Control #:
US-00426
Format:
Word;
Rich Text
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In section 2, select the "GET" information box and enter the name and address of the hospital, school, physicians, clinic, laboratory, pharmacy, insurer or. By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above.PATIENT INFORMATION. Name. If you have any questions, please email or call .