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UNIVERSITY OF NORTH FLORIDA DEPARTMENT OF ATHLETICS Authorization for Use, Disclosure, and Release of Health Information Student-Athlete / Patient Print Name Address Date of Birth City State Zip Code

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How to fill out authorization of release for

How to fill out authorization of release form:

01

Start by providing your personal information, including your full name, contact information, and any relevant identification numbers such as a social security number or driver's license number.

02

Specify the purpose of the authorization, such as granting permission for the release of medical records, employment records, or educational transcripts.

03

Indicate the specific individuals or organizations that are authorized to receive the requested information. Include their names, addresses, and contact information.

04

Determine the duration of the authorization, whether it is a one-time release or valid for a specific period of time. Specify the start and end dates if applicable.

05

Include any limitations or restrictions on the release of information. This could include excluding certain sensitive or confidential information from the release.

06

Sign and date the authorization form. If required, have the form notarized to ensure its validity.

07

Make a copy of the completed authorization form for your records before submitting it to the appropriate party.

Who needs authorization of release form:

01

Patients who want to share their medical records with other healthcare providers or insurance companies may need to fill out an authorization of release form.

02

Job applicants may be required to provide an authorization of release form to give potential employers access to their educational and employment records.

03

Individuals who are involved in legal proceedings, such as a lawsuit or divorce case, may need to fill out an authorization of release form to grant permission for the disclosure of relevant information.

Please note that the specific requirements and procedures for filling out an authorization of release form may vary depending on the jurisdiction and purpose of the release. It is recommended to consult with the relevant authority or legal counsel for accurate and up-to-date information.

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