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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT OCA Official Form No. 960 TO HIPAA This form has been approved by the New York State Department of Health Patient Name Date of Birth Social Security Number Patient Address I or my authorized representative request that health information regarding my care and treatment be released as set forth on this form In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 I-...
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