Document
Authorization for Use or Disclosure of Health Information Form
ICR 201609-0915-001 · OMB 0915-0334 · Object 67923301.
This document may belong to an older filing. More recent activity for OMB 0915-0334:
Document Viewer [doc]
Status: No verified local artifact is currently available. The document remains flagged for repair and upstream re-check.
Queue: Repair is queued and waiting for the next worker pass. (priority 20 · next 2026-06-04 06:58:44)
Missing: pdf, html
No local or Spaces-backed artifact is available yet for this document.
Loading document viewer…
Document Metadata
| File Type | application/octet-stream |
|---|---|
| File Title | Authorization for Use or Disclosure of Health Information Form |
| Author | rwalsh1 |
| Last Modified By | EPioli |
| File Modified | 2016-08-24 |
| File Created | 2016-08-24 |
| Conversion State | failed_conversion |