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Name: Fillable Online Authorization to Obtain Information From Pharmacies and Pharmacy Records Fax Email Print - pdfFiller
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This document serves as an authorization form for individuals participating in the Medical Expenditure Panel Survey (MEPS), allowing the U.S. Department of Health and Human Services to obtain medical and financial information about prescriptions filled or refilled by the participant for the specified period. It explains the rights of participants under HIPAA and details the conditions under which the provided information will be used and protected.

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Panel 24 refers to a specific reporting section or form used for financial or regulatory purposes, typically within the context of tax filings or compliance reports.

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