Nih 1208: Fill out & sign online

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Click ‘Get Form’ to open the nih 1208 in the editor.
Begin by filling out the CC PATIENT IDENTIFICATION section. Enter the patient's name, patient number, and date of birth accurately.
In the SOURCE OF INFORMATION REQUESTED section, provide the name of the health care organization or physician, along with their street address, phone number, city, state, and zip code.
Clearly state the purpose or need for disclosure in the designated area.
If requesting military records, include the sponsor's name and social security number.
Identify specific items and related dates for information requested. Fill in details for medical reports, x-ray films and reports, and pathological slides as needed.
Complete the AUTHORIZATION section by signing and providing your printed name, address, city, state, and zip code.

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Versions	Form popularity	Fillable & printable
2013	4.8 Satisfied (47 Votes)

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