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Glue 5Hole 1×4 1 3×8 CTC AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Initial here if requesting information from Centennial Hills Hospital Medical Center. Note: There will be
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What is initial here if requesting?
Initial here if requesting is a form of authentication or approval.
Who is required to file initial here if requesting?
The individual or entity requesting approval or authorization is required to file initial here.
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To fill out initial here, simply write or place your initials in the designated space provided.
What is the purpose of initial here if requesting?
The purpose of initial here if requesting is to signify agreement, consent, or approval.
What information must be reported on initial here if requesting?
The relevant party's initials must be reported on initial here if requesting.
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