Davis Mobility Company

Authorization Form

AUTHORIZATION For Davis Mobility Co to:
Use and Disclose Health Information

I understand that this organization wishes to use or disclose the following protected health information:

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I understand that the following person or class of persons is authorized to use or disclose this protected health information:

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I understand that this information will be used or disclosed to:

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I understand that this authorization expires on:  _____________________ 
  [insert date or event]
 

I understand that I may revoke this authorization in writing.

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Signature of Patient or Legal Representative

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Witness

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Date

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Effective Date

TO ORDER CALL:



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