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Andrew Charles Bowman

WEBAndrew Bowman – [email protected] – (214) 794-8897 2 University of Texas Health – San Antonio, TX (Ophthalmology Dept.) 1. The Jiri Eye Study (JES) Dec. 2016 …

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Cornea Associates of Texas

WEBBy signing this form, you consent to Cornea Associates’ use and/or disclosure of protected health information about you for treatment, payment, health care

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CONFIDENTIAL HEALTH HISTORY

WEBCONFIDENTIAL HEALTH HISTORY Patient Name: _____ Date of Birth: ___ I. CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question) 1. Yes / …

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Patient Health History

WEBHas anyone in your family had any of the following? If yes, please list relationship . Y / N Cataract_____ Y / N Retinal Tear/Detachment_____

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Cornea Associates of Texas

WEBCornea Associates of Texas. Revised 12.20.19 . MEDICARE and/or MEDICAID: Medicare Number: _____ Medicaid Number: _____ PRIMARY INSURANCE (Complete with …

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Authorization for Release of Information/Medical Records …

WEBAuthorization for Release of Information/Medical Records Release I, _____, DOB: ____/____/_____, SS# _____-_____-_____, hereby

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Dear Sweet Tooth Dental Patients,

WEBSweet Tooth Dental Inc 77-6443 Kuakini Hwy Kailua-Kona, HI 96740 808-329-0889 November 1, 2023 Dear Sweet Tooth Dental Patients, We are posting this letter to …

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Informed Consent for Photographic Release

WEBBenjamin J. Boudreaux, MD Jeffrey R. Claiborne, MD Informed Consent for Photographic Release Patient Name Address (street address, city, state and zip code)

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Augusta Drive Dental Care 1011 Augusta Dr, Suite 201 …

WEBJon M Van Slate, DDS,FAGD,LVIF, FIAPA Augusta Drive Dental Care 1011 Augusta Dr, Suite 201 Houston, Texas 77057 (713) 783-1993 [email protected]

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Jordan Marie Comstock, M.D.

WEBCornea Associates of Texas 10740 N. Central Expy., Suite 350 Dallas, TX 75231 (Dallas, Plano, and Rockwall Offices) [email protected].

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HIPAA Notice of Privacy Practices Acknowledgement 2022

WEBWe are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices …

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JONATHAN I. MACY, M.D. 8635 West Third Street, Suite 360W …

WEBJONATHAN I. MACY, M.D. 8635 West Third Street, Suite 360W Los Angeles, CA 90048 310.657.2777.office 310.657.0356.fax Dear Patient: The purpose of this letter is to help …

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einsteinclients.com

WEBWashington Foot and Ankle NOTICE OF PRIVACY PRACTICES / Your Rights Chanda Corbin, DPM, FACFAS 174 S Main Street Romeo, Ml 48065 586-372-7200

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KARSKI Orthodontics SPOKANE ORTHODONTICS

WEBPRIVACY CONSENT This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services.

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