Medical Information Request Form Template



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Medical Information Request Form Template

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Request for Leave or Approved Absence – OPM

www.opm.gov

additional information about your entitlements … Certification: I hereby request
leave/approved absence from duty as indicated above and certify that such leave
/absence is requested … approved absence (and provide additional
documentation, including medical certification, if required) and that falsification
on this form may.

Request for Employment Information – CMS.gov

www.cms.gov

DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR
MEDICARE & MEDICAID SERVICES. Form Approved. OMB No. 0938-0787.
REQUEST FOR EMPLOYMENT INFORMATION. SECTION A: To be completed
by individual signing up for Medicare Part B (Medical Insurance). 1. Employer's
Name. 2. Date.

General Release For Medical Provider Information – Veterans …

www.vba.va.gov

SECTION I – PATIENT IDENTIFICATION FOR RECORDS VA IS REQUESTING.
GENERAL RELEASE FOR MEDICAL PROVIDER INFORMATION. TO THE
DEPARTMENT OF VETERANS AFFAIRS (VA). INSTRUCTIONS – COMPLETE
AND ATTACH THIS FORM WITH A SIGNED VA FORM 21-4142,
AUTHORIZATION TO …

Authorization for the Release of Medical Information NIH-527

clinicalcenter.nih.gov

MEDICAL RECORD. Authorization for the Release of Medical. Information.
INSTRUCTIONS: Complete this form in its entirety and forward the original to the
address below: Please complete a separate form for each requestor. NATIONAL
… This authorization may be revoked at any time upon your request. If you would
like …

VA Form 10-5345 – Veterans Affairs

www.va.gov

release) is not furnished completely and accurately, VA will be unable to comply
with the request. The Veterans Health Administration may not condition treatment
, payment, enrollment or eligibility on signing the authorization. VA may disclose
the information that you put on the form as permitted by law. VHA may make a.

Request Pertaining to Military Records, SF 180 (11-15)

www.archives.gov

The Standard Form 180, Request Pertaining to Military Records (SF180) is used
to request information from military records. … Personnel Records/Military Human
Resource Records/Official Military Personnel File (OMPF) and Medical Records/
Service Treatment. Records (STR). Personnel … Obtain the forms by e- mail from
 …

Form: Medical request – Minnesota Department of Labor and Industry

www.dli.mn.gov

Medical Request. PRINT IN INK or TYPE. ENTER DATES in MM/DD/YYYY
FORMAT. NOTE: Before filing this form, call the workers' compensation insurer. If
that does not resolve the issue, … For more information, call the Alternative
Dispute Resolution Unit at (651) 284-5032 or 1-800-342-5354. YES. NO. 1. THIS
REQUEST …

Consent for Release of Information – Social Security

www.ssa.gov

acting on behalf of a minor child, you may complete this form to release only the
minor's non-medical records. We may charge a fee for providing information
unrelated to the administration of a program under the Social Security Act. NOTE:
Do not use this form to: • Request the release of medical records on behalf of a
minor …

Responding to Unsolicited Requests for Off-Label Information … – FDA

www.fda.gov

21 animal drug products (drugs) and medical devices (devices) can respond to
unsolicited requests for … regard to such products, a request for “off-label
information” refers to any request for information regarding a new use … 27
indications or conditions of use (on-label information) for FDA-regulated medical
products. It.

Access to Government Records Under the Maryland Public …

www.marylandattorneygeneral.gov

Maryland's Public Information Act (“PIA”) gives the public the right to access
government records without … individual's medical information, confidential
commercial information and trade secrets). GP §§ 4-304 to … No, although some
agencies have created request forms to help the agency respond to. PIA requests
. In some …

practical advice for drafting and implementing reasonable – EEOC

www.eeoc.gov

limit the information sought on request confirmation forms to name, contact
information, date of request, date of form, office, accommodation requested and
reason for request. See Attachment A (sample form for confirmation of
reasonable accommodation requests). Additional information (including medical
documentation) …

Authorization to Disclose Protected Health Information

www.texasattorneygeneral.gov

form that complies with HIPAA, the Texas Medical Privacy Act, and … prior actions
taken in reliance on this authorization by entities that had permission to access
my health information will not be affected. SIGNATURE … If requesting a copy of
the individual's health records with this form, state and federal law allows such …

Form W-9 – IRS.gov

www.irs.gov

Form W-9. (Rev. November 2017). Department of the Treasury. Internal Revenue
Service. Request for Taxpayer. Identification Number and Certification. ▷ Go to
www.irs.gov/FormW9 for instructions and the latest information. Give Form to the
requester. Do not send to the IRS. Print or type. See. Specific Instructions on
page …

customer medical report – Virginia DMV

www.dmv.virginia.gov

Feb 25, 2017 Purpose: Use this form to request medical information from your physician,
physician assistant or nurse practitioner. Instructions: Follow the detailed
INSTRUCTIONS printed on page 2. Complete the Customer Information and
Information Release. Approval sections on this page. Take the entire MED 2 and
 …

Motor Vehicle Record Request – Arizona DOT

www.azdot.gov

notarized Consent to Release Motor Vehicle Record–One-Time, form # 96-0463,
must be attached) (Permissible Use #13). Only if a box is checked for one or
more of the six permissible uses above, may the requester specifically request
the person's driver license photograph/image or medical/disability information.

Civil Rights Information Request For Medicare … – HHS.gov

www.hhs.gov

Civil Rights Information Request. For Medicare Certification. Form Approved.
OMB No. 0945-0006. Exp. Date 04/30/2017. II. Documents Required for
Submission (Continued). For guidance or to obtain sample policies and
procedures, please visit the OCR Technical Assistance for Medicare Providers
and Applicants web …

Request for Motor Vehicle Information – NCDOT

www.ncdot.gov

The Federal Driver's Privacy Protection Act requires that personal information in
DMV records be closed to the public. … that qualify under one of the fourteen
exceptions listed on the back of this form. … photos, social security numbers,
driver license numbers, names, addresses, telephone numbers and medical
information.

Form I-693 – USCIS

www.uscis.gov

Report of Medical Examination and Vaccination Record. Department of
Homeland Security. U.S. Citizenship and Immigration Services. USCIS. Form I-
693. OMB No. 1615- … Part 1. Information About You (To be completed by the
person requesting a medical examination, NOT the …. Date Blood Sample Drawn
(mm/dd/yyyy).