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Search results with tag "As follows"

FEDERAL EMPLOYEE PROGRAM DESIGNATION OF ... - FEP Blue

FEDERAL EMPLOYEE PROGRAM DESIGNATION OF ... - FEP Blue

www.fepblue.org

As necessary for this appeal, I authorize the use and disclosure of y m protected health information. 1. as follows: I authorize the Blue Cross and Blue Shield Federal Employee Program (FEP) to release protected health information including all medical records, medical rationale, or relevant reference materials

  Health, Information, Release, Blue, Protected, Follow, Protected health information, Fep blue, Release protected health information, As follows

REPORT OF ADDICTION EVALUATION DRIVER LICENSE …

REPORT OF ADDICTION EVALUATION DRIVER LICENSE …

www.dot.nd.gov

automatically as follows: Qualified Professional Signature License Number Date Specify the date, event, or condition upon which this consent expires. Notice to Whomever Disclosure is Made Concerning Addiction Records . This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2).

  Information, Protected, Follow, As follows

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