Authorization For Release Of Information Health Information Report Form A
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1Division of Public Health - Department of Health and Human Services
Department of Health & Human Services
FORM A:
Authorization for Release of Information
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Last Name:
First Name:
Middle Initial(s):
Street or Mailing Address:
Street Address:
State:
Zip Code:
I authorize the release of information regarding my __________________________________________________________ condition to
representatives of the Nebraska Department of Health and Human Services, Division of Public Health, Office of Children’s
Services Licensing for the purpose of determining compliance with licensing regulations and evaluating my fitness to provide
care/services in a safe, competent, ethical and professional manner.
Such privileged information shall be released by the following: (One source only. Use additional form for each additional
source).
Name of Treating Physician:
Address:
City:
State:
Zip Code:
Phone Number:
_______________________________________________________________________________________________________
_________________________________________
Signature of Applicant
Date
Distribution: WHITE COPY - OFFICE OF CHILDREN’S SERVICES LICENSING; CANARY COPY - PROVIDER
CRED-0915 9/15
.
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Parent category: Legal