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SafeTaper Inc. Authorization for Release of Protected Health Information (PHI)
Instructions
This form authorizes SafeTaper Inc. to release or obtain protected health information (PHI) as specified below. Please complete all sections accurately. Incomplete forms may delay processing. Consult with SafeTaper Inc. staff if you have questions.
1. Client Information
Full Name:
*
Date of Birth:
*
Address:
*
Phone:
*
Email:
*
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