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AuthorizationtoReleaseInformationAnd/Records(OUT) NameofClient: DOB: I, hereby authorize: TheCarolynE. WylieCenterforChildren, YouthandFamilies 4164BrocktonAvenue Riverside,California92501 (951)6835193Phone(951)6836019Fax

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How to fill out authorization to release records

Point by point, here is how to fill out an authorization to release records:

01

Start by clearly identifying the purpose of the authorization. Specify whether it is for medical records, educational records, financial records, or any other type of records.

02

Include the name and contact information of the person or entity releasing the records. This could be a healthcare provider, school, bank, or any other organization that holds the records.

03

Provide the name and contact information of the person or entity receiving the records. This could be an individual, another organization, or a specific department within an organization.

04

Clearly list the specific records or information that you authorize to be released. Be as specific as possible to avoid any confusion. For medical records, you might specify the dates of treatment, the types of records (such as lab results or progress notes), and the healthcare providers involved.

05

State the purpose for which the records will be released. This could be for medical treatment, legal proceedings, insurance claims, or any other legitimate purpose.

06

Specify the duration of the authorization. You can choose to make it valid for a one-time release only or for a specific period of time. If you want the authorization to remain in effect indefinitely, be sure to mention that as well.

07

Include any limitations or restrictions on the release of records. For example, you may want to exclude certain sensitive information or specify that the authorization does not cover psychotherapy notes.

08

Sign and date the authorization form. If applicable, provide any required witness signatures or notarization.

Regarding who needs authorization to release records, it depends on the specific situation and the laws of your jurisdiction. In general, individuals or organizations that hold confidential records are required to obtain authorization before releasing them to anyone else. This could include healthcare providers, educational institutions, financial institutions, government agencies, or any other entity with access to private records. However, it is always best to consult the relevant laws and regulations in your jurisdiction to determine the specific requirements for obtaining authorization to release records.

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