Authorization for release of Protected Health Information (PHI) - North ...
North Florida Regional Medical Center Fax: 855-668-0697 Phone: 888-616-5721 Section A: This section must be completed for all Authorizations - * Required * Patient Name: * ... that the released information may contain alcohol, drug abuse, genetic information, psychiatric, HIV testing, HIV results or AIDS information. _____ (Initial) I ... ................
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