Release of Information Forms. Respondent shall sign all release of information forms as required by the Board or its designee and return them to the Board within 10 days of the Board’s written request. Failure to provide for the release of information, as required by this paragraph constitutes noncompliance with this Order. ARIZONA STATE BOARD OF NURSING __________________________________________ Xxxx Xxxxxxxx, R.N., M.N., F.A.A.N. Executive Director Dated: 2/4/2021 JR/CG:ll // // // // // // // // // // Transmitted for Respondents signature this 4th day of February, 2021, via Adobe Sign to: Xxxxxxx Xxxxxxx of East Valley Institute Of Technology Practical Nursing Program: xxxxxxxx@xxxx.xxx /// /// /// /// Fully Executed copy sent this 17 day of February , 2021, via Adobe Sign to: Xxxxxxx Xxxxxxx of East Valley Institute Of Technology Practical Nursing Program: xxxxxxxx@xxxx.xxx Signed in the Board Office on February, 17 , 2021. By: Xxx Xxxxxxxxx Administrative Assistant Xxxx Xxxxx Executive Director Governor Xxxx Xxxxxxxx Arizona State Board of Nursing 0000 Xxxx Xxxxx Xxxxxx, Suite 2000 Phoenix, AZ 00000-0000 Phone (000) 000-0000 | Home Page: xxxx://xxx.xxxx.xxx February 17, 2021 Xxxxxxx Xxxxxxx East Valley Institute of Technology Sent Via Secure Email: xxxxxxxx@xxxx.xxx Re: FINAL Consent Agreement and Order Number 200205PN96103000 Dear Xxxxxxx Xxxxxxx: Please see the enclosed duly signed Consent Agreement for Probation. The effective date of this order is February 4, 2021. All terms of the agreement are listed in the actual document but as a courtesy I have outlined some dates for you to be aware of: ● Within seven days of the effective date of this Order, the Board shall note the probationary status of the program on the list of approved programs with the following notation: “FULL - Active Consent Agreement.” Additionally the Board shall provide public access to this order through its website. ● Within 7 days of each assigned quarterly reporting due date, Respondent shall provide the Board with accurate and complete quarterly reports containing the following:
Release of Information Forms. Respondent Program shall cause an authorized program representative to sign all release of information forms as required by the Board or its designee and return them to the Board within 10 days of the Board’s written request. Failure to provide for the release of information, as required by this paragraph constitutes noncompliance with this Order.
Release of Information Forms. 9.1) Contractor shall maintain records on any release of information forms in accordance with DVR standards. (DVR Confidentiality (xxxxxxxxx.xxx).
Release of Information Forms. Participants must sign all required Release of Information forms as requested by the service providers and can rescind those documents for any reason during the duration of this program.
Release of Information Forms. Respondent shall sign all release of information forms as required by the Board or its designee and return them to the Board within 10 days of the Board’s written request. Failure to provide for the release of information, as required by this paragraph constitutes noncompliance with this Order. ARIZONA STATE BOARD OF NURSING _______________________________________ _ Xxxx Xxxxxxxx, R.N., M.N., F.A.A.N. Executive Director Dated: November 19, 2021 JR/KM:yf Transmitted this 18th day of November, 2021, via Adobe Sign to: Xxxxxx Xxxxxxxx, Xxxxxxxxxx College, ADN Program-Mesa Campus: xxxxxx.xxxxxxxx@xxxxxxxxxx.xxx Xxxxxxxx Xxxxx, Xxxxxxx xxxxxx@xxxxxxxxxx.xxx By: _ X. Xxxxxxx Legal Secretary
Release of Information Forms. Respondent shall sign all release of 18 information forms as required by the Board or its designee and return them to the Board within 10 days of the Board’s written request. If Respondent fails to execute the releases, license holder may be subject to disciplinary action.
Release of Information Forms. 20 If the Board or its designee makes a written request for Respondent to sign a 21 release of information form to review or enforce compliance with this Order, Respondent 22 must sign and return the release to the Board within ten (10) days of the Board’s written
Release of Information Forms. Respondent shall sign all release of information forms as required by the Board or its designee and return them to the Board within 10 days of the Board’s written request. Failure to provide for the release of information, as required by this paragraph constitutes noncompliance with this Order. ARIZONA STATE BOARD OF NURSING SEAL Xxxx Xxxxxxxx, R.N., M.N., F.A.A.N. Executive Director Dated: JR/CG:ll Sent via secure email on 8/5/2019 to: xxxx.xxxxxxxxxx@xxxxx.xxx Xxxx signed copy mailed this 12th day of September , 2019 via email xxxx.xxxxxxxxxx@xxxxx.xxx and U.S. Certified Mail certificate number: 7016 0750 0000 4921 6835 to: Xxxxxxx of Northern Arizona Xxxx Xxxxxx 809-a and X Xxxx Xxxxxxx Way Prescott, AZ 86305 Signed in the Board Office this 12th day of September , 2019. By: Xxx Xxxxxxxxx
