Nih 527 Form PDF Details

The Nih 527 form is an application to request a waiver of the two-year foreign residence requirement for J-1 visa holders. The form must be submitted by the applicant, and the decision to grant or deny the waiver is made at the discretion of U.S. Citizenship and Immigration Services (USCIS). The waiver may be granted if there is a compelling reason why the applicant cannot return to their home country after completing their program in the United States. There are several factors that USCIS will consider when making this determination, including whether or not the applicant has strong family ties in their home country and whether they would experience hardship if they were forced to leave the United States.

The table includes specifics of the nih 527 form. You might want to look at it prior to filling out the form.

QuestionAnswer
Form NameNih 527 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnih form 527, nih medical records, nih527, nih 527 form

Form Preview Example

MEDICAL RECORD

Authorization for the Release of Medical

Information

INSTRUCTIONS: Complete this form in its entirety and forward the original to the address below: Please complete a separate form for each requestor

NATIONAL INSTITUTES OF HEALTH

 

 

 

 

ATTN: MEDICAL RECORD DEPARTMENT

 

 

 

 

MEDICOLEGAL SECTION

 

 

 

 

10 CENTER DRIVE, MSC 1192

TELEPHONE:

(888)

790-2133 (outside calling area)

BLDG 10, ROOM 1N205

 

(301)

496-3331

(local calls)

BETHESDA, MD 20892-1192

FACSIMILE:

(301)

480-9982

 

IDENTIFYING INFORMATION:

Patient Name

Daytime Telephone

Date of Birth

REQUESTOR INFORMATION: Information is to be released to the following individual or party:

Name

Telephone

Address

Fax Number

City

State

Zip Code

Country

*Please note that a patient may designate up to two outside care providers to have permanent authorization to obtain copies of their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers, please choose one of the following:

Please give the above named care provider authorization to my medical records

Please replace _____________ (existing authorization) with the above named care provider

Please remove the above named care provider’s authorization

The purpose or need for disclosure: ________________________________________________________________

Date Range of Information to be Released: from

to

 

(month/year)

 

(month/year)

Please check specific information to be released:

 

 

Discharge Summary

History & Physical

Operative Reports

Outpatient Progress Notes

Other (Please Specify):

Consultation Reports

Pulmonary Function Tests

Tissue Exam Reports

Nuclear Medicine Reports Nuclear Medicine CD Images (bone scan, etc.)

Heart Diagnostics

Radiology Reports Radiology CD Images (CT/x-ray, etc.)

Lab Results

AUTHORIZATION: Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above.

(Note: submission of this form authorizes the release of the information specified within one year from date of signature.)

Patient/Authorized Signature

Print Name

Date

Patient Identification

Authorization for the Release of Medical Information NIH-527 (9-08)

P.A. 09-25-0099

File in Section 4: Correspondence

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