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AUTHORIZATION/CONSENT FOR USE OR DISCLOSURE OF INFORMATION FOR PUBLICATION PURPOSES Part I. Name and Address of Individual Last First MI Last 4 digits of Social Security Number: Address: Date of Birth:
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Start by reading the instructions provided on the form carefully. This will give you a clear understanding of what information needs to be filled in and how.
02
Begin by entering your personal information in the appropriate fields. This may include your full name, address, contact information, and any other requested details.
03
If the form requires you to provide consent for a specific purpose, make sure to read and understand the purpose clearly. If you agree with the purpose, check the relevant box or provide your consent in the designated area.
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If there are any sections or fields that are not applicable to you, leave them blank or mark them as N/A (not applicable) as instructed.
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Review the filled form for any errors or omissions before submitting it. Double-check your information to ensure accuracy.
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If required, sign and date the form in the designated space to validate your consent.
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Organizations or businesses that seek consent from individuals for legal, contractual, or ethical reasons may use this form.
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Schools, healthcare institutions, research organizations, and other similar entities may require consent from individuals, making this form necessary.
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