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FEDERAL EMPLOYEE PROGRAM DESIGNATION OF ... - FEP Blue
www.fepblue.orgAs 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
REPORT OF ADDICTION EVALUATION DRIVER LICENSE …
www.dot.nd.govautomatically 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).