Customer Authorization Form

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.

(Sample Form)

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Feel free to reach out to us. We’re available by phone during regular business hours to answer any questions you might have.

856.273.5761

You can also email us and we’ll get back to you within 24 hours.