dhb-7097-ia Recipient Request and Authorization to Disclose Health Information

Form Numberdhb-7097-ia
Medicaid Form Numberdhb-7097-ia
Agency/DivisionHealth Benefits/NC Medicaid (DHB)
Form Effective Date 2021-04-21T00:00:00-04:00
Form File DHB-7097-IA_ Beneficiary Authorization to Disclosure Health Information.pdf