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Gary Y. Liao D. P. M. Diplomate ABPM Melissa S. Hill D. P. M. Diplomate ABPM Alan E. Sotelo D. P. M. Authorization to release Protected Health Information PHI to / from Central Carolina Foot Ankle Associates circle one Patient Name Date of Birth Patient Address Phone Phone Request Date I hereby request and consent to the rele release ase and disclosure of my personal health information from / to circle one Facility/Doctor/Person Address Please include Check all that apply Please send this PHI...
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What is liao d?
Liao d is a financial disclosure form.
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Liao d must be filed by individuals or entities required to disclose financial information.
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The purpose of liao d is to provide transparency and accountability in financial matters.
What information must be reported on liao d?
Liao d must include information such as income, assets, liabilities, and investments.
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