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6
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HIPAA
Compliance
1
Who is the patient?
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First Name
Last Name
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2
Patient Date of Birth
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Date
Month
Day
Year
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3
Which provider are you sending this for to?
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Dr. Mark Hunter
Dr. Angie Paddack
Susan Puckett
Dr. Mark Hunter
Dr. Angie Paddack
Susan Puckett
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4
Email (to send the form back to you)
example@example.com
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5
Phone Number
Please enter a valid phone number.
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6
Please browse for the form you wish to upload
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