Get form ihs

Description of form ihs
IHS-810 4/09 FRONT FORM APPROVED OMB NO. 0917-0030 Expiration Date 1/31/2013 See OMB Statement on Reverse. PATIENT IDENTIFICATION NAME Last First MI RECORD NUMBER DATE OF BIRTH PSC Graphics 301 443-1090 EF BACK Instructions for Completing IHS Form 810 -AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION 1. 8. A copy of the completed IHS-810 form will be given to you. OMB STATEMENT Public reporting...
Fill & Sign Online, Print, Email, Fax, or Download
Fill Online
  • Fill Online
  • eSign
  • eFax
  • Email
  • Add Annotation
  • Share
form ihs
Rate This Form