INS Health Care Program Authorization for
Disclosure of Information

United States Department of Justice
Immigration and Naturalization Service

(Pursuant to the Privacy Act of 1974, Public Law 93-579)
To:
INS Location (please circle):
Name

AGUADILLA , BATAVIA , EL CENTRO, EL PASO, FLORENCE
KROME, PORT ISABEL, SAN PEDRO, VARICK

Street Address

City, State ,

OTHER:

ZIP

You are hereby authorized to furnish information from my record/ the record of:
Detainee’s Name:

A#

in the medical record system of your facility to :
Requester’s Name:
Requester’s Address:
Street Address

City, State

ZIP

Any person who knowingly and willfully requests or obtains any record concerning an individual from a Federal Agency
under false pretenses shall be guilty of a misdemeanor and fined not more than $5000 (5 U.S.C. 552a(i)(3)) and in the
case of alcohol and drug abuse patient records a falsified authorization of disclosure is prohibited under 42 CFR 2.31(d)
and is punishable by a fine of not more than $500 for a first offense or a fine of not more than $5000 for a subsequent
offense with 42 CFR 2.14.
Purpose or need for the disclosure:

Specify extent and nature of information to be disclosed for
each purpose or need indicated (include inclusive dates of treatment.)

Further Medical Care
Attorney
Other (Specify)
Duration of Consent (Period of time or the circumstance(s) during which disclosures may be made pursuant to this autnorization.)
From:

Until:

Signature of Detaine e(Applican t)

Addres s of Detain ee (Applica nt):

Street

IMPRINT OF DETAINEE ID PLATE OR COMPUTER
LABEL OR COMPLETE THE FOLLOWING:
1. Name (Last,

First)

2. DO B :

3. A#

City, State, Z IP

4. Nationality:

Form I-813 (01-17-90)