Forms Catalog Document - 912 :-: IHS :-: Request For Revocation of Restriction(s)

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Request For Revocation of Restriction(s)

This form is used to request for revocation of restriction(s) on health records.

Form #: 912 2
Agency: Department of Health and Human Services
Bureau: Indian Health Service
Common Name: Revoke Disclosure Restriction on Health Information

	TYPE	PAGES	SIZE (KB)	CAPABILITY	WHAT'S NEEDED
	Form Only	1	249	[3] Fillable + Printable	Adobe Reader Download
	Form Only	1	45	[3] Fillable + Printable	Other Client Software

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