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MEDICATION ASSISTANCE AUTHORIZATION 20162017 (Authorization signed/dated by doctor after June 30, 2016) Student Name: SIS#: D.O.B. Address: School: Grade: Teacher: Parent/Guardian Phone: Home: Work:

How to fill out authorization signeddated by doctor

How to fill out authorization signed/dated by doctor:

1. Begin by reviewing the authorization form carefully and ensuring that you understand the purpose and requirements of the authorization.
2. Fill in your personal information accurately, including your full name, date of birth, and contact details.
3. Identify the organization or individual that you are authorizing and provide their relevant information, such as their name, address, and contact details.
4. Specify the scope and purpose of the authorization clearly, describing exactly what actions or information you are authorizing the organization or individual to access or perform.
5. Ensure that you sign and date the authorization form in the designated spaces. This will serve as proof that you are providing your consent willingly.
6. If required, provide any additional information or documentation that may be necessary to support your authorization.
7. Retain a copy of the completed authorization form for your records.
8. If applicable, submit the authorization form to the relevant organization or individual as per their instructions.

Who needs authorization signed/dated by doctor:

1. Patients who want to authorize their healthcare providers or hospitals to release their medical records to a third party, such as another doctor or insurance company.
2. Individuals who are granting consent for specific medical procedures or treatments and want to document this authorization.
3. Parents or legal guardians who need to authorize medical treatment or procedures for a minor or incapacitated person under their care.
4. Researchers or healthcare organizations who need authorization from patients in order to conduct studies or use their medical information for research purposes.
5. Insurance companies or legal entities who require signed authorization from a doctor to process claims or release medical information for legal proceedings.

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