Nhjb-2171-Fp - Department Of Health And Human Services Record Release Authorization

Download a blank fillable Nhjb-2171-Fp - Department Of Health And Human Services Record Release Authorization in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Nhjb-2171-Fp - Department Of Health And Human Services Record Release Authorization with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Instructions
Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
DEPARTMENT OF HEALTH AND HUMAN SERVICES
RECORD RELEASE AUTHORIZATION
(RSA 170-B:18, VI and 463:5, VI and 464-A:4, V)
To:
Department of Health and Human Services and all its divisions
I hereby authorize the release of any child or adult abuse and/or neglect record that you may find concerning
me to the
,
(name of court)
at
(address of court)
1. Name
Mailing address
2. Also known by following names
(example: maiden name)
Official Use Only
3. Date of birth
4. List other states where you have resided as an adult and when
I understand that the information disclosed and provided by you under this
request and release authorization is intended for use by the above named
court, in conjunction with the above referenced matter and subject to any
confidentiality requirements applicable to such legal proceeding.
Date
Signature
State of
, County of
This instrument was acknowledged before me on
by
Date
Person Signing Above
My Commission Expires
Affix Seal, if any
Signature of Notarial Officer / Title
The court requires that the search be conducted and the information be provided as specified above.
PER ORDER OF THE COURT,
Date
Clerk of Court
Top of page
NHJB-2171-FP (08/29/2014)
Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Department Of Health And Human Services Plague Case Investigation Report Department Of Health And Human Services Plague Case Investigation Report Business
Department Of Health And Human Services Checklist Test Plan Department Of Health And Human Services Checklist Test Plan Business
Department Of Health And Human Services Family Medical Leave/family Illness Leave Request Form Department Of Health And Human Services Family Medical Leave/family Illness Leave Request Form Business
Aphis/cdc Form 3 - Report Of Theft, Loss, Or Release Of Select Agents And Toxins - Department Of Health And Human Services Aphis/cdc Form 3 - Report Of Theft, Loss, Or Release Of Select Agents And Toxins - Department Of Health And Human Services Legal
New Hampshire Early Childhood Health Assessment Record - Nh Department Of Health And Human Services New Hampshire Early Childhood Health Assessment Record - Nh Department Of Health And Human Services Legal
Form Dhhs 1662 - Nursing Record Of Tuberculosis Contacts Form - U.c. Department Of Health And Human Services Form Dhhs 1662 - Nursing Record Of Tuberculosis Contacts Form - U.c. Department Of Health And Human Services Legal
Form Dss-1812 - General Authorization For Treatment And Medication - North Carolina Department Of Health And Human Services Form Dss-1812 - General Authorization For Treatment And Medication - North Carolina Department Of Health And Human Services Legal
Form Cms-588 (08/06) - Electronic Funds Transfer (eft) Authorization Agreement - Department Of Health And Human Services Form Cms-588 (08/06) - Electronic Funds Transfer (eft) Authorization Agreement - Department Of Health And Human Services Business
Form Cms-588 (05/10) - Electronic Funds Transfer (eft) Authorization Agreement - Department Of Health And Human Services Form Cms-588 (05/10) - Electronic Funds Transfer (eft) Authorization Agreement - Department Of Health And Human Services Business
Form Dss-1688 - Designation Of Authorized Representative - North Carolina Department Of Health And Human Services Form Dss-1688 - Designation Of Authorized Representative - North Carolina Department Of Health And Human Services Legal

Related Categories

Parent category: Business
Download
Go