Date of disclosure Name of PersonEntity Description of Information to be disclosed Copy of written request YesNo If no information must not be released ROI completed to release the Informati ID: 849194
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1 METNURSE HEALTH SERVICES, INC. Discl
METNURSE HEALTH SERVICES, INC. Disclosure of Personal Health Information Name of individual:_______________________________________________ Services:_______________________ Date of disclosure Name of Person/Entity Description of Information to be disclosed Copy of written request? (Yes/No). If no, information must not be released. ROI completed to release the Information.(Yes/No)If no, information must not be released. Signature Signature of Staff