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OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF ...
www.nycourts.govAUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] Patient Name Date of Birth Social Security Number Patient Address I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:
Form 6-K - SEC
www.sec.govB. Information and Documentation Required to be Furnished. Subject to General Instruction D herein, an issuer furnishing a report on this form shall furnish whatever information, not req uired to be furnished on Form 40-F or previously furnished, such issuer (i) makes or is required to make public pursuant to the law o f the
SEC1673 10-K.indd CF Daniel Morris - SEC.gov | HOME
www.sec.govCommission pursuant to Rule 14a-3(b) or Rule 14c-3(a) or from the registrant’s annual report to security holders, even if not furnished to the Commission pursuant to Rule 14a-3(b) or Rule 14c-3(a), provided such annual report contains the information required by Rule 14a-3. Note 1.
NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF …
www.health.ny.gov2) Collect insurance policy information from family (10 NYCRR 69-4.6(d)). a. Service Coordinators should give the family Form B (Child Insurance Information) and the form instructions. Service Coordinators should review the instructions with the parents and assist them with completing Form B (Child Insurance Information). b.
Information * Denotes Required Fields
forms.fbi.govThe FBI’s acquisition, retention, and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16.30-16.34. The purpose for requesting this information from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of FBI identification records.