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Get HHS IHS-810 2009

Print legibly in all fields using dark permanent ink. 2. Section I, print your name or the name of patient whose information is to be released. 3. Section II, print the name and address of the facility releasing the information. Also, provide the name of the person, facility, and address that will receive the information. 4. Section III, state the reason why the information is needed, e.g., disability claim, continuing medical care, legal, research-related projects, etc. 5. Section IV, check the.

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