REPORT OF NON-ROUTINE DISCLOSURES by armedman1

VIEWS: 8 PAGES: 1

									                         REPORT OF NON-ROUTINE DISCLOSURES


Patient Name:                                                                           DOB:




                                                                                             Copy Auth/Request Attached
   Date of         Recipient Name             Description of
                                                                              Purpose                                 Date/Last
 Disclosure          & Address                 Information                                    #Disclosure
                                                                                                                      Disclosure


                                                                                         Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached



                                                                                        Copy of Auth/Req Attached

               —

                                                                                        Copy of Auth/Req Attached

                                                                                            ITEM 070-6002/25943 ® MAY 2002
Please contact the Privacy Officer at the address above with any questions.

								
To top