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Medical informatics / Medicine / Government / Healthcare in the United States / Health Insurance Portability and Accountability Act / Veterans Health Administration / Social Security / Medical record / Information privacy / Health / Taxation in the United States / United States Department of Veterans Affairs


OMB Number: [removed]Estimated Burden: 2 minutes REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION Privacy Act and Paperwork Reduction Act Information: The execution of this form does not au
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Document Date: 2011-10-26 11:43:43

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File Size: 388,40 KB

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City

Seattle / /

Company

WA 98124 VETERAN / /

IndustryTerm

health care services / /

Organization

UN Court / Department of Veterans Affairs / Veterans Health Administration / SOCIAL SECURITY NUMBER NAME AND ADDRESS OF ORGANIZATION / INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED Seattle Municipal Court / VA Regional Office / Information Unit / /

ProvinceOrState

Virginia / Washington / /

RadioStation

WHOM / /

SocialTag