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NORTHSIDE PARK GASTROENTEROLOGY & ENDOSCOPY CENTER, LLC AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patients Name: Date of Birth: Previous Name: Social Security #: I request and authorize: Name:

How to fill out authorization to release information

How to fill out authorization to release information:

1. Start by filling out the top section of the form, which typically includes your personal information such as your name, address, phone number, and date.
2. Identify the entity or individual you are authorizing to release information. This could be a healthcare provider, educational institution, employer, or any other party who may have access to your personal information.
3. Be specific about the type of information you are authorizing to be released. This could include medical records, academic transcripts, employment history, or any other relevant information.
4. Specify the purpose for which the information is being released. Is it for insurance claims, background checks, academic applications, or any other specific purpose?
5. Include the duration of the authorization. You can choose to specify a specific time period for which the authorization is valid, or you can leave it open-ended.
6. Sign and date the form, and ensure that it is witnessed or notarized, depending on the requirements of the organization you are authorizing.
7. Keep a copy of the completed authorization form for your records.

Who needs authorization to release information:

1. Healthcare providers: In order for doctors, hospitals, and other healthcare professionals to share your medical records with other individuals or organizations, they typically require a signed authorization form.
2. Educational institutions: If you want your academic records, such as transcripts or recommendations, to be shared with other schools or employers, you may need to provide an authorization to release information.
3. Employers: When requesting previous employment history, conducting background checks, or verifying information about an employee, employers often require the individual's authorization to release information.
4. Insurance companies: In order to process claims or obtain medical records, insurance companies may ask for an authorization to release information.
5. Government agencies: Certain government agencies, such as the Social Security Administration or the Internal Revenue Service, may require authorization to release personal information for specific purposes.

Overall, anyone who has access to personal or confidential information about you will generally require your authorization in order to release that information to another party.

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