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Chronic Illness Benefit application form 2015

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Academic year: 2021

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INDIVIDUAL AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION With my signature on this application I authorize any physician, healthcare provider,

I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information and including consultation reports, to

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In the event of illness or injury to my child while on this travel/activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care

In the event of illness or injury to my child while on this travel/activity, I hereby give my consent for medical or dental care deemed necessary by the attending health care

AUTHORIZATION TO RELEASE INFORMATION: In obtaining payment for services, I authorize my healthcare provider and the clinic to furnish information form my medical records to any