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Fidelity Land Title, Ltd 309 S Main St Jefferson WI 53549 www.thelandoffice.com pH:(920×6743913 FX: (920×6745532 closings thelandoffice.com AUTHORIZATION TO RELEASE INFORMATION The undersigned is×are
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How to fill out bauthorizationb to release information
How to fill out an authorization to release information:
01
Start by clearly stating your name and contact information at the top of the form.
02
Indicate the purpose of the authorization, such as whether it is for medical records, employment history, or financial information.
03
Provide the name and contact information of the individual or organization from whom you are requesting the information.
04
Specify the duration of the authorization, including the start and end dates for which the information can be released.
05
Include any specific details or restrictions regarding the information to be released. This could include certain documents, specific dates, or types of information.
06
Sign and date the authorization form. If applicable, have a witness also sign and provide their contact information.
07
Keep a copy of the signed authorization for your records.
Who needs an authorization to release information?
01
Patients: If you want your medical records to be shared with another healthcare provider or if you are applying for disability benefits and need access to your medical information, you will need to fill out an authorization.
02
Employers: When conducting background checks or verifying employment history, employers may require an authorization to release information from previous employers.
03
Creditors and financial institutions: In order to obtain a consumer's credit report or financial information, creditors and financial institutions typically require an authorization to release information.
04
Legal representatives: Attorneys or legal representatives may need an authorization to release information in order to gather evidence for a case or to obtain records from government agencies.
05
Researchers and academic institutions: Researchers and academic institutions may require an authorization to release information when conducting studies or collecting data for research purposes.
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