Search results with tag "Authorization for disclosure of consumer"

Authorization for Disclosure of Consumer Med/Health Info

THE SPECIFIC INFORMATION TO BE DISCLOSED IS (CHECK ALL THAT APPLY) (nAme oF ConSumeR, pARent, guARdiAn/legAl RepReSentAtive) (nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon) (nAme oF FACility, AgenCy, mentAl heAlth CenteR, peRSon) (AddReSS, City, …

  Health, Information, Consumer, Authorization, Disclosures, Authorization for disclosure of consumer