Dd Form 2628 PDF Details

Dd form 2628 is an authorization to release medical information to another person or organization. The form can be used to authorize the release of information for both military and non-military purposes. The release of information can be for the purpose of treatment, payment, or healthcare operations. The form must be completed and signed by the individual who has authority to authorize the disclosure of medical information. Completed forms should be kept on file with the healthcare provider. Dd Form 2628 is also known as: Authorization for Disclosure of Protected Health Information (APHIS)

QuestionAnswer
Form NameDd Form 2628
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesIP, APR, FormFlow, 2006

Form Preview Example

 

OMB No. 0704-0347

REQUEST FOR APPROVAL OF CONTRACTOR FLIGHT CREWMEMBER

OMB Approval Expires

 

Jul 31, 2007

 

 

The public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0347). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE GOVERNMENT FLIGHT REPRESENTATIVE.

1. FROM (Name and Address of Contractor's Requesting Official)

2. TO (Name and Address of Government Flight Representative)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. CONTRACTOR'S REQUESTING OFFICIAL (CRO).

 

 

 

 

 

 

 

 

 

I have verified the records of (Crewmember's name)

 

 

 

 

and request that he/she be approved

as a (crew position)

 

 

 

 

 

 

 

 

for (Strike out all inapplicable) experimental/engineering/acceptance/

production/functional/support flights in

 

 

 

 

type aircraft.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. TYPED NAME (Last, First, Middle Initial)

 

B. SIGNATURE

 

 

 

 

C. DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. INSTRUCTOR PILOT/FLIGHT EXAMINER (IP/FE)

 

 

 

 

 

 

 

 

 

I certify that the crewmember above has satisfactorily flown a proficiency flight check on (Date)

 

 

.

 

 

 

 

 

 

 

 

 

 

A. TYPED NAME (Last, First, Middle Initial)

 

B. SIGNATURE

 

 

 

 

C. DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

5. GOVERNMENT FLIGHT REPRESENTATIVE (GFR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPROVED

 

A. TYPED NAME (Last, First, Middle Initial)

 

B. SIGNATURE

 

C. DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISAPPROVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DD FORM 2628, APR 2006

 

PREVIOUS EDITION IS OBSOLETE.

FormFlow/Adobe Professional 7.0

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