Health Disclosure Form

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH AND/OR OTHER INFORMATION

Pursuant to 45 CFR § 164.508(c) & § 164.512, NRS 127.255 & NRS 127.152

Authorization to Disclose Protected Health and/or Other Information

Pursuant to 45 CFR § 164.508(c) & § 164.512, NRS 127.255 & NRS 127.152

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The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)(Required)
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Check box to acknowledge:(Required)