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AUTHORIZATION TO DISCLOSE SCD MH PROTECTED HEALTH INFORMATION, at (Name of requestor)Address (Street, City, State, Zip) DOB, SS#, Medical Record # authorize the release of my SCDMHhealth information,
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The name of the requestor is the individual or entity making the request.
The person or organization submitting the request is required to provide their name as the requestor.
To fill out the name of the requestor, simply provide the full legal name of the individual or entity making the request.
The purpose of providing the name of the requestor is to identify who is making the request and establish accountability.
The name of the requestor must include the full legal name of the individual or entity making the request.
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