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Requesting AHCH Provider
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Primary Care Physician
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PCP’s Address
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PCP’s Phone #
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PCP’s Fax #
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Description of release
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Patient Authorization for AHCH to receive and release PHI from/to PCP
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Patient Declination for AHCH to receive and release PHI from/to PCP
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PCP, please mail or fax the following information to Assured Hope Community Health, LLC
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Patient Rights
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Signature section
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