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DEPARTMENT OF PUBLIC SAFETY / P.O. BOX 1628 / SANTA FE, NM 87504-1628 ATTN: RECORDS $15.00 PER RECORD CHECK AUTHORIZATION FOR RELEASE OF INFORMATION I, NAME (MUST BE PRINTED-LEGIBLY) (SSN#) (DOB)

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How to fill out authorization release of information

How to fill out an authorization release of information form:

01

Start by providing your personal information, including your full name, date of birth, address, and contact information. This ensures that the released information is correctly associated with you.

02

Next, indicate the specific information you are authorizing to be released. This could include medical records, educational records, financial information, or any other relevant documents. Be as specific as possible to avoid any confusion.

03

Specify the purpose of the release of information. This could be for legal purposes, medical treatment, insurance claims, or any other applicable reason. Clearly state the reason to ensure that only the necessary information is released.

04

Include the names and contact information of the individuals or organizations that are authorized to release or receive the information. If there are multiple parties involved, provide their details separately to avoid any confusion.

05

Specify the timeframe during which the authorization is valid. This allows you to control how long the release of information remains valid. You may choose to specify an end date or indicate that the authorization is valid until revoked.

Who needs an authorization release of information?

01

Patients: Individuals who wish to allow their healthcare providers or other relevant parties to release their medical information to specific individuals or organizations will need to fill out an authorization release of information form.

02

Students: Students who want to authorize their schools or educational institutions to release their educational records to other institutions or potential employers will also need to complete an authorization release of information form.

03

Legal purposes: Individuals involved in legal matters, such as court cases or insurance claims, may need to provide authorization for their legal representatives to access and release their personal or relevant information.

04

Researchers: Individuals participating in research studies may need to authorize the release of their personal information to researchers or research institutions involved in the study.

In summary, anyone who wants to authorize the release of their personal information to specific individuals or organizations for various purposes will need to fill out an authorization release of information form. It is essential to provide accurate and complete information to ensure the smooth processing of the release request.

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