Get the free YOU MUST PROVIDE COMPLETED MAILING ADDRESS, OR THIS FORM WILL BE RETURNED TO YOU (eng)

PO Box 15645 * Las Vegas, NV 891145645 * Fax: (702) 5602878 Authorization to Disclose Protected Health Information (PHI) This request to RELEASE medical records will be returned if not completed in

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How to fill out you must provide completed

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5. Submit the filled-out form through the designated method, whether it be online, in-person, or by mail.
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1. Individuals who are applying for a visa or immigration status.
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5. Patients who need to complete medical forms for appointments or procedures.
6. Anyone who is required to provide information or documentation for legal or administrative purposes.

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