INSTRUCTIONS: This form should be completed when you terminate employment with Fairfax County. In Re: Fiduciary No. RECEIPT.Use and Disclosure We may use or disclose your PHI for treatment, payment, or health care operations. Learn what an acknowledgement receipt is and how to create one for your business (with a template and two examples). View, modify, and fill in tenant authorization form fairfax easily with FormsPal! A trusted online platform to use and forms without hassle. This manual is intended to assist persons who are involved in the administration of a decedent's estate in Virginia. Do not use the signing option when filling out the forms. If this is you, then you may find working in the Instrumentation Maintenance Branch of Fairfax County's Wastewater Mgmt. Terms used but not defined herein have the meanings set forth in the Form 40-F.