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6
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HIPAA
Compliance
1
Who is the patient?
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First Name
Last Name
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2
Patient Date of Birth
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Date
Month
Day
Year
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3
Which provider are you sending this for to?
*
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Dr. Lauren Brave (Foothills)
Dr. Kristen Geiger (Foothills)
Dr. James Gottlieb (Foothills)
Dr. Chesney Kennedy (Foothills)
Dr. Karin Knapp (Foothills)
Dr. Margaret Lafferty (Foothills)
Dr. Allen Ruan (Foothills)
Dr. Neha Vaitha (Foothills)
Dr. Cheryl Cavanaugh (Avista)
Dr. Maureen Dickerson (Avista)
Dr. Timothy Jaeger (Avista)
Dr. Andrea Mertz (Avista)
Dr. Melissa Serlen (Avista)
Dr. Lauren Brave (Foothills)
Dr. Kristen Geiger (Foothills)
Dr. James Gottlieb (Foothills)
Dr. Chesney Kennedy (Foothills)
Dr. Karin Knapp (Foothills)
Dr. Margaret Lafferty (Foothills)
Dr. Allen Ruan (Foothills)
Dr. Neha Vaitha (Foothills)
Dr. Cheryl Cavanaugh (Avista)
Dr. Maureen Dickerson (Avista)
Dr. Timothy Jaeger (Avista)
Dr. Andrea Mertz (Avista)
Dr. Melissa Serlen (Avista)
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4
Email (to send the form back to you)
example@example.com
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5
Phone Number
Please enter a valid phone number.
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6
Please browse for the form you wish to upload
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