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Directory Results for AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INATION Information About the Use or Disclosure I hereby authorize the use or disclosure of my protected health information (PHI) as described below: Individuals Name: Date of to Authorization for Use and/or Disclosure Of Protected Health Ination to Schools MEDICAL RECORD #: PATIENT INFORMATION (Please Print): Last Name First Name Middle Initial Maiden Name (if applicable) Address City State Zip Code Date of

AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INATION Information About the Use or Disclosure I hereby authorize the use or disclosure of my protected health information (PHI) as described below: Individuals Name: Date of
Authorization for Use and/or Disclosure Of Protected Health Ination Patient Information (Please Print) Last Name First Name Middle Initial Address City State Date of Birth Gender Zip Code Social Security Number (Optional) Phone Number
Authorization for Use and/or Disclosure Of Protected Health Ination to Schools MEDICAL RECORD #: PATIENT INFORMATION (Please Print): Last Name First Name Middle Initial Maiden Name (if applicable) Address City State Zip Code Date of