Fillable FORM A: RELEASE I hereby authorize all hospitals, (State of Nevada, Department of Information Technology)

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FORM A: RELEASE I hereby authorize all hospitals, (State of Nevada, Department of Information Technology)

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FORM A
RELEASE
I hereby authorize all hospitals, medical institutions or organizations, my references, personal
physicians, employers (past and present), business and professional associates (past and present), and all
governmental agencies and instrumentalities (local, state, federal or foreign) to release to the Nevada State
Board of Medical Examiners any information, files or records required by the Nevada State Board of Medical
Examiners for its evaluation of my professional, ethical, physical, and mental qualifications for licensure in
the state of Nevada.
DATED this __________ day of _____________________________, _______.
Signature: ____________________________________________
Typed or Printed Name: ____________________________________________
(NOTARY SEAL)
A photocopy of this form will serve as an original (Board use only).
Please return completed form to:
Nevada State Board of Medical Examiners
9600 Gateway Drive
Reno, NV 89521
State of _______________ County of _________________
Subscribed and sworn to before me this __________ day of
_______________________________, ___________.
Notary Public for the State of ________________________
My Commission Expires: ____________________________
Residing at: ______________________________________
City State
________________________________________________
Signature of Notary
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FORM A: RELEASE I hereby authorize all hospitals, (State of Nevada, Department of Information Technology)

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Completed 26 October 2021

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