mk0iwspremier4tiahpw.kinstacdn.com · the above-named doctor may use my health care information and...

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Page 1: mk0iwspremier4tiahpw.kinstacdn.com · The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their
Page 2: mk0iwspremier4tiahpw.kinstacdn.com · The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their
Page 3: mk0iwspremier4tiahpw.kinstacdn.com · The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their