Annual Data Authorization Form
Annual Data Authorization Form
This form is designed to authorize the use and disclosure of healthcare data.
Program Information
Program
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Medicare
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Medicaid
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Children's Health Insurance Program (CHIP)
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Enrollment ID No.
Contract ID No.
Enrollment Start Date
Service Start Date
Assigned Staff
Authorization for Service
I have been informed about the specified program and wish to receive services. I understand that my personal health information will be collected, maintained, and securely stored in a database to track services and ensure quality care is provided. This data may be used for evaluation, billing, and compliance purposes. I hereby authorize myself and/or my dependent(s) to receive these services as part of the selected healthcare program.
Name:
Date:
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