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OTHER
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Directory Results for AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INATION Name of patient (and maiden name if applicable) whose records will be disclosed Patient s birth date Patient s I-Number Name of requesting individual (person completing this form) - to Authorization for use and disclosure of health ination-Number 1.docx

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INATION Name of patient (and maiden name if applicable) whose records will be disclosed Patient s birth date Patient s I-Number Name of requesting individual (person completing this form) -
Authorization for Use and Disclosure of Health Ination Patient ...
AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INATION Patient Name: DOB: MRN: Address: City: State: Zip: Phone: Email (optional): Type of Access Requested: Paper Copy CD or USB Drive Inspection Only Email (encrypted) Other (must be agreed upon b
Authorization for use and disclosure of health ination-Number 1.docx