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HIPAA Release
Patient name:
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Authorization to Disclose Health Information to Family Members and Friends
  I authorize the release of health information to the individuals listed below:
Information allowed to disclose(Check all that apply)
Name Relationship Medical Billing Make/ Cancel
Appointments
Pick up/ Place
orders
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HIPAA Privacy Policy HIPAA Privacy Policy Acknowledgement: I acknowledge that I was offered a copy of Dr. Michael Klautzsch O.D., Dr. Justin Heintz O.D., and Dr. Kelly Shannon O.D. notice of privacy practices.

Patient HIPAA Form: {{ hipaa.first_name }} {{ hipaa.last_name }}

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