Authorization for Use or Disclosure of Health Information Form

Countermeasures Injury Compensation Program (CICP)

OMB: 0915-0334

IC ID: 208416

Documents and Forms

Document Name Document Type
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction
Form 2 Authorization for Use or Disclosure of Health Information Form Form and Instruction
2 CICP Authorization Form 03132023 - CICP Authorization Form- OMB 0915-0334.PDF Form and Instruction
1 CICP Authorization Form in Spanish - Redline 10112023 - (23) CICP Authorization Form 2020 in Spanish - REDLINE.docx Form
1 CICP Authorization Form Instructions in Spanish - Redline 10112023 - (24) CICP Authorization Form Instructions in Spanish - REDLINE.docx Form and Instruction