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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.

Question	Answer
Form Name	Nih 527 Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	25
Avg. time to fill out	5 min 19 sec
Other names	hospice care communicator form dma 527, nih patient information, nih 527 sp, nih medical records

12

Form Preview Example

Phone #:

Fax #:

MEDICAL RECORD

Authorization for the Release of Medical Information

	National Institutes of Health, Clinical Center	INSTRUCTIONS: This form must be completed in its entirety, each
	Health Information Management Dept.	section must be completed or the form could be returned as
	10 Center Drive, MSC 1192	invalid.
	Building 10, Room B1L400	For more information or to submit this form electronically, please
	Bethesda, MD 20892-1192
	Bethesda, MD 20892-1192	visit our website:
	Phone: (888) 790-2133 or (301) 496-3331	visit our website:
	Phone: (888) 790-2133 or (301) 496-3331	https://clinicalcenter.nih.gov/participate/medicalrecordrequest.html
	FAX: (301) 480-9982	Please complete a separate form for each requestor
		Please complete a separate form for each requestor

1. PATIENT INFORMATION:

Patient Name:

Phone Number:

Date of Birth:

2.ACTION: Up to two outside care providers can have permanent authorization to obtain copies of medical records. This authorization may be revoked at any time upon your request. If the below named individual is not a healthcare provider, please skip this step.

Add New Care Provider - Please give the below named care provider access to my medical records.

Replace Authorized Care Provider - Replace existing care provider ___________with the below named care provider.

Remove Authorized Care Provider - Please remove the below named care provider’s access.

3.RELEASE INFORMATION TO: Who do you want to receive the requested records - Full Mailing Address Required.

Phone and fax are optional. All other fields are required

Name:

Address:

City:

State:

Zip Code:

Country:

4.INFORMATION TO BE RELEASED: Review options and check appropriate box(es):

DATES OF SERVICE TO BE RELEASED: From ______________ to _______________

☐Clinical Notes

☐Radiology Reports

☐Radiology Images (will be released on a CD)

☐Pathology Reports

☐Lab results

☐Other Diagnostic Test Results (Cardiac, Pulmonary Function, Neurological Testing, etc.)

☐Other (Please Specify) :

5.THE PURPOSE OR NEED FOR DISCLOSURE (Continued Care, Personal Use,etc):

6.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 future disclosures to the same individual and/or entity within one year from date of signature.

Patient/Authorized Signature

Print Name

Date

Patient Identification (Staff Use Only)

Authorization for the Release of Medical Information NIH-527 (7-21)

P.A. 09-25-0099

File in Section 4: Correspondence

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These parts will frame the PDF document that you'll be creating:

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The application will need you to fill in the Print, Name Date, and Patient, Identification, Staff, Use, Only segment.

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