Authorization For Disclosure Of Health Information {A-25R} | Pdf Fpdf Docx | Maryland

 Maryland /  Workers Compensation /  Adjudication Claims /
Authorization For Disclosure Of Health Information {A-25R} | Pdf Fpdf Docx | Maryland

Authorization For Disclosure Of Health Information {A-25R}

This is a Maryland form that can be used for Adjudication Claims within Workers Compensation.

Alternate TextLast updated: 6/3/2019

Included Formats to Download
$ 13.99

Description

000002003004005003006007b002tn005013006fr016002013b002tt016006006016002013 017020021000002003004005003006007021b002tn005013006fr016002013021b002tt016006006016002013021f022r023002003016024fr016002013021025002003021026016006b027002006022003005021002025021023005f027r023021016013025002003tfr016002013021 f030031032033034035031036021b002t f003021037 !"#!"$!"%&'021()*+,,021-.+021/0112,,20)021034+3,0210-.+352,+021603021700402189:,+021,.05);0219021<93-=021,.9**021<30> 24+021-00219)=0210-.+3021<93-=;0210)021532--+)0213+?:+ ,-;02190211+4289*0219:-.032@9-20)021030213+*+9,+A021021 BA021021C+3,0)021/0> +3+4021D=021B:-.032@9-20)021E.2,021408:1+)-0219:-.032@+,021-.+02142,8*0,:3+02106021<30-+8-+4021.+9*-.0212)60319-20)0213+7934 2)7'021F91+G/*9219)-021 H9-+02106021I23-.021 IA021C:3<0,+02106021H 2,8*0,:3+021 E.2,021408:1 +)-0219:-.032@+,021-.+02142,8*0,:3+02106021<30-+8-+4021.+9*-.0212)60319-20)021603021-.+021<:3<0,+02106021<308+,,2)7;02194J:42 89-2)70219)40213+,0*>2)7021503K+3,L021801<+ ),9-20)0218*921,A021021 /A021021M)-2-2+,021B: -.032@+4021-0021N9K+021H2,8*0,:3+021 E.2,021408:1 +)-0219:-.032@+,0219)=021.+9*-.021<*9);021<.=,2829);021.+9*-.021893+021<306+,,20)9*;0214+)-2,-;021.0,<2-9*;0218*2)28;021*9D039-0 3=;021<.93198=;0211+4289*0216982*2-=;021030210-.+ 3021.+9*-.021893+021<30>24+3021-.9-021.9,021<30>24+4021<9=1+)-;021-3+9-1+)-02103021,+3>28+,021-00211+021030210)0211=021D+.9*6021-0 02142,8*0,+0211=021<30-+8-+4021.+9*-.0212)60319-2 0)02180),2,-+)-02152-.021-.2,021423+8-2>+A021021 HA021021M)-2-2+,021B: -.032@+4021-0021O+8+2>+021C30-+8-+4021P+9*-.021Q)60319-20)021 E.2,021408:1 +)-0219:-.032@+,021-.+02142,8*0,:3+021060211=021<30-+8-+4021.+9*-.0212)60319-20)021-0021-.+02160**052)7021+)-2-2+,0219)4021-.+2302197 +)-,'0210211=0219--03)+=;0211=021+1<*0=+3;0211 =021+1<*0=+3L,021503K+3,L021801<+),9-20)0212),:3+3;021-.+021()2),:3+4021M1<*0=+3,L021R:)40219)4021-.+021S:D,+?:+)-021Q)J: 3=021R:)4A021021MA021Q)60319-20)021 -0021D+02142,8*0,+4021E.2,021408:1+)-0219:-.032@+,021-.+021+)-2-2+,021*2,-+40212)021/021-002142,8*0,+021<30-+8-+4021.+9*-.0212)60319-20 )021-.9-0212,0213+*+>9)-021TUVWAE.+0211+1D+ 302106021-.+021D04=021-.9-02159,0212)J:3+4' XAE.+0214+,832< -20)02106021.05021-.+02198824+)-9*0212)J:3=021088:33+4' YAE.+0214+,832< -20)02106021.05021-.+021088:<9-20)9*02142,+9,+021088:33+4' E.+021<30-+8-+4021. +9*-.0212)60319-20)021-.9-02119=021D+02142,8*0,+40212)8*:4+,;021D:-0212,021)0-021*212-+4021-0'021.2,-03=;02162)42)7,;02106628+0219)4 021<9-2+)-0218.93-,;02162*+,;021+Z912)9-20)0219)4 021<3073+,,021)0-+,;0219)4021<.=,289*021+>24+)8+A021021 RA021Q021:)4+3,-9)4021 -.9-021Q02119=0213+>0K+021-.2,0219:-.032@9-20)021D=02172>2)7021532--+)021)0-28+021-00219**021<93-2+,021-00211=0218*921021603021503K+3,L02180 1<+),9-20);021+Z8+<-021-0021-.+021+Z-+)-021-.9 -021-.2,0219:-.032@9-20)021.9,0219*3+94=021D++)02198-+40210)021<3203021-00213+8+2<-021060211=0213+>089-20)A021 Q021:)4+3,-9)4021-. 9-021-.+0212)60319-20)02142,8*0,+4021D=021-.2,0219:-.032@9-20)02119=021D+021,:DJ+8-021-00213+42,8*0,:3+021D=021-.+0213+82<2+ )-021-002190211+4289*02119)97+3;021.+9*-. 021893+021<306+,,20)9*021030213+72,-+3+40213+.9D2*2-9-20)021<398-2-20)+3;0219)40210-.+3,02180),2,-+)-02152-.021,-9-+0219)40216+4+39*021 *95A021021I=021,27)2)7021-.2, 0216031;021Q021910219:-.032@2)7021-.+02142,8*0,:3+021060211=021<30-+8-+4021.+9*-.0212)60319-20)A021E.2,0219:-.032@9-20)0212,021>9*24 0216030210)+021=+93021[\]^021`a021bca021`de021[]\^ 021de021edfgabh021 C9-2+)-G/*9219) -021S27)9-:3+'021iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiH9-+'021iiiiiiiiiiiiiiiiiiiii 021 f021j032033031033k033j036l021mnko035p035qr021033034021rqrk031034033s035k021031034nsop035oo035033s021033m021031032035o021o035tsru021n030031032033034035vn031035033s021m033034p021035o021wnq035u!021 xy021z{021|}~T200U201202021203T201202202T204021|}~T200U201202204021205206021207x207y207210x211212x213214214021215U201200021216210207217220021y221210207yx222 American LegalNet, Inc. www.FormsWorkFlow.com

Our Products