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29Sep/130

INDIVIDUAL AUTHORIZATION FORM

INDIVIDUAL AUTHORIZATION (for release of PHI from Provider to to a copy of this authorization. Date Individual Signature *Note: This form cannot be used for psychotherapy notes. If you seek to authorize the use or disclosure of http://www.anthem.com/provider/noapplication/f4/s6/t0/pw_ad090005.pdf%3frefer=ahpprovider%26state=nh Preview Download Filesize:...