Request And Authorization For Release Of Information Form printable pdf download

Request And Authorization For Release Of Information Form

Request and Authorization for

Release of Information

Please type or print information to send to third party. Scores are automatically provided to PA.

Duplicate as needed.

Section 1: Identification

Name:______________________________________________________________________________

Address: ____________________________________________________________________________

City: ________________________________ State:___________ Zip:___________________________

Daytime Telephone: (______) ______-_________

NCCPA Identification #_______________________

Section 2: Exam Information

Indicate which exam and examination period you’re requesting information. One request per form.

PANCE (Physician Assistant National Certifying Exam)

PANRE (Physician Assistant National Recertifying Exam)

Pathway II

Year:_________

Section 3: Information Request

Indicate the nature of this request and the person or agency to whom it should be sent.

Eligibility letter, verifying that you are eligible for and registered to take the above exam

Exam results

Name:______________________________________________________________________________

Agency: ____________________________________________________________________________

Address: ____________________________________________________________________________

City: ________________________________ State:___________ Zip:__________________________

Section 4: Signature and Authorization

Each state licensing authority sets its own rules and regulations. We will only send the requested

information, which may consist of current scores and/or score history, to the person or agency listed above.

It is your responsibility to stay up-to-date on individual requirements.

I acknowledge that I have read and understand the above statement and authorize NCCPA to release

all information required by the agency listed above.

_________________________________________________

_____________________

(signature)

(date)

Please remember that it is your responsibility to update state medical boards, your employer(s)

and other interested parties of any changes in your certification status.

Fax completed form to 678.417.8135, email credentialing@nccpa.net or mail to:

NCCPA, 12000 Findley Road, Ste. 100, Johns Creek, GA 30097-1409.

Request And Authorization For Release Of Information Form