Oca Official Form No 960
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Oca Official Form No 960
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Date of Issuance November 9 2013 Effective upon release all Partial MLTC MAP and PACE plans must use the OCA Official Form No 960 for new enrollees when seeking authorization of the release of enrollee prospective enrollee protected health Fill out this HIPAA authorization form to allow the release of your health information for legal, research, or personal purposes. Download the PDF and print or email it to the University of Rochester Medical Center.
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Oca Official Form No 960OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIP AA (This form has been approved by the New York State Department of Health) Patient Name I Date of Birth I. These instructions will help you to complete the Authorization for Release of Health Information under the HIPAA OCA 960 It is important that you read each line of the form carefully and that you make sure you fill in each box correctly Failure to complete the form may result in HRA disapproving your request
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