GB-12 HIPAA Authorization for Dependent Child Medical Information Request Form

Office of Group Benefits

This government document is issued by Office of Group Benefits for use in Louisiana

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File Details: PDF (351 KB)
Downloads: 1
Source
https://info.groupbenefits.org/docs/OGBforms/Agencies/GB12AuthorizationForReleaseOfDependentChildPHIAccessible03132026.pdf

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