Epstein Secrets

ocess. 1. Race, check all that apply: K White K Black, African-American c American Indian/Alaska Nativ

nitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain

ss MA 877-6277745 MA $35.00 04:135 04/05 CKE'BLACK ARROW 26 C BEVERLY MA $64.58 04105 04/05 USP

e been disclosed to you from records whose privacy is protected from disclosure by federal and state law including, as applicable, 45 CFP Part 160 (HIPAA), 42 CFP Part 2 (alcohol and drug treatment) and other state laws. The applicable law or laws may prohibit you from making any further disclosure wi

ocess. 1. Race, check all that apply: K White o Black, African-American L; American IndiarVAlaska Nati

nitedHealthcare representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain

rocess. 1. Race. check all that apply: L White Black. African-American Y. Native Hawaiia&Pacitic Isla

UnitedHealthcare representative in wnting, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA. UnitedHealthcare also requires that I acknowledge the following, which I do. I understand that information I authorize a person or entity to obtain

address and telephone number of destination: Roy Black Miami, FL 33131 Purpose of Trip: prepare for

t DOC privacy procedures should be directed to the DOC Privacy Officer at . Complaints to DOC about the way DOC handles your PHI, compliance with HIPAA (see footnote, p.1 of this Notice), or if you believe your privacy rights have been violated must be filed as Offender Grievances pursuant to Rule 3

address and telephone number of destination: Roy Black 305-371-6422 201 S Biscayne Blvd. Miami, FL 3313

t DOC privacy procedures should be directed to the DOC Privacy Officer at . Complaints to DOC about the way DOC handles your PHI, compliance with HIPAA (see footnote, p.1 of this Notice), or if you believe your privacy rights have been violated must be filed as Offender Grievances pursuant to Rule 3