Loading
Form preview picture

Get NIH-527 2008-2024

Patient/Authorized Signature Patient Identification Print Name Date NIH-527 9-08 P. A. 09-25-0099 File in Section 4 Correspondence. Authorization for the Release of Medical Information MEDICAL RECORD INSTRUCTIONS Complete this form in its entirety and forward the original to the address below Please complete a separate form for each requestor NATIONAL INSTITUTES OF HEALTH ATTN MEDICAL RECORD DEPARTMENT MEDICOLEGAL SECTION 10 CENTER DRIVE MSC 1192 BLDG 10 ROOM 1N205 BETHESDA MD 20892-1192 TELEPHONE 888 790-2133 outside calling area 301 496-3331 local calls FACSIMILE 301 480-9982 IDENTIFYING INFORMATION Patient Name Daytime Telephone Date of Birth REQUESTOR INFORMATION Information is to be released to the following individual or party Name Telephone Address Fax Number City State Zip Code Country Please note that a patient may designate up to two outside care providers to have permanent authorization to obtain copies of their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers please choose one of the following Please give the above named care provider authorization to my medical records Please replace existing authorization with the above named care provider Please remove the above named care provider s authorization The purpose or need for disclosure Date Range of Information to be Released from to month/year Please check specific information to be released Discharge Summary History Physical Operative Reports Outpatient Progress Notes Consultation Reports Pulmonary Function Tests Tissue Exam Reports Nuclear Medicine Reports bone scan etc* Heart Diagnostics Radiology Reports Radiology CD Images CT/x-ray etc* Lab Results Other Please Specify AUTHORIZATION Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above. Note submission of this form authorizes the release of the information specified within one year from date of signature. Authorization for the Release of Medical Information MEDICAL RECORD INSTRUCTIONS Complete this form in its entirety and forward the original to the address below Please complete a separate form for each requestor NATIONAL INSTITUTES OF HEALTH ATTN MEDICAL RECORD DEPARTMENT MEDICOLEGAL SECTION 10 CENTER DRIVE MSC 1192 BLDG 10 ROOM 1N205 BETHESDA MD 20892-1192 TELEPHONE 888 790-2133 outside calling area 301 496-3331 local calls FACSIMILE 301 480-9982 IDENTIFYING INFORMATION Patient Name Daytime Telephone Date of Birth REQUESTOR INFORMATION Information is to be released to the following individual or party Name Telephone Address Fax Number City State Zip Code Country Please note that a patient may designate up to two outside care providers to have permanent authorization to obtain copies of their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers please choose one of the following Please give the above named care provider authorization to my medical records Please replace existing authorization with the above named care provider Please remove the above named care provider s authorization The purpose or need for disclosure Date Range of Information to be Released from to month/year Please check specific information to be released Discharge Summary History Physical Operative Reports Outpatient Progress Notes Consultation Reports Pulmonary Function Tests Tissue Exam Reports Nuclear Medicine Reports bone scan etc* Heart Diagnostics Radiology Reports Radiology CD Images CT/x-ray etc* Lab Results Other Please Specify AUTHORIZATION Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above. .

How It Works

nih records rating
4.91Satisfied
44 votes

Tips on how to fill out, edit and sign Clinical release of information online

How to fill out and sign Nih medical records form online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Finding a legal specialist, making a scheduled visit and going to the workplace for a personal conference makes doing a NIH-527 from start to finish exhausting. US Legal Forms helps you to quickly generate legally binding papers based on pre-built browser-based blanks.

Prepare your docs in minutes using our simple step-by-step instructions:

  1. Find the NIH-527 you want.
  2. Open it up with online editor and begin editing.
  3. Fill the empty fields; concerned parties names, addresses and phone numbers etc.
  4. Customize the template with smart fillable areas.
  5. Put the date and place your electronic signature.
  6. Click on Done following double-checking all the data.
  7. Save the ready-created papers to your device or print it as a hard copy.

Quickly produce a NIH-527 without needing to involve experts. There are already over 3 million users taking advantage of our unique collection of legal forms. Join us right now and gain access to the #1 collection of browser-based samples. Give it a try yourself!

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing nih form 527

Go through the most up-to-date methods in digital management. Complete Form quickly using our simple step-by-step video instructions.

Nih records request FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to NIH-527

  • institutes
  • bldg
  • Attn
  • facsimile
  • authorizes
  • Providers
  • Diagnostics
  • entirety
  • OUTPATIENT
  • designate
  • specified
  • MD
  • BETHESDA
  • specify
  • disclosure
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.