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	SCMA MEMBERS’ INSURANCE TRUST AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Member Name______________________________________________________ Date of Birth ___________________________ ID Number________ Add to Reading List Document Date: 2012-08-10 08:57:49 Open Document File Size: 295,50 KB Share Result on Facebook

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SCMA MEMBERS’ INSURANCE TRUST AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Member Name______________________________________________________ Date of Birth ___________________________ ID Number________Add to Reading List