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Mahoning County Career & Technical Center 7300 N. Palmyra Road Canfield, OH 44406 330-729-4000 RELEASE OF INFORMATION AUTHORIZATION FORM Parent/Guardian and students applying to programs listed below

How to fill out release of information authorization

How to fill out release of information authorization:

1. Obtain the form: First, you will need to obtain a release of information authorization form. This form may be provided by your healthcare provider, therapist, or other relevant organizations.
2. Read the instructions: Before you start filling out the form, carefully read the instructions provided. The instructions will guide you on how to properly complete each section of the form and ensure you provide all the necessary information.
3. Personal information: Begin by filling out your personal information, including your full name, address, date of birth, and contact details. Make sure to provide accurate and up-to-date information.
4. Specify the purpose: Indicate the specific purpose for which you are authorizing the release of information. For example, if you want your medical records to be shared with another healthcare provider, clearly state the reason for this request.
5. Specify the information to be released: In this section, you should specify the exact information you authorize to be released. It could be general medical records, specific test results, psychiatric evaluations, or any other relevant information. Be as specific as possible to avoid any confusion.
6. Specify the recipient: Clearly state the name and contact information of the individual or organization who will receive the information. This can be a doctor, therapist, insurance company, or any other authorized entity. Double-check the accuracy of the recipient's details.
7. Authorization duration and revocation: Indicate the duration for which the authorization is valid. Some authorizations may have an expiration date, while others may be valid indefinitely. Additionally, understand that you have the right to revoke this authorization at any time by submitting a written request.
8. Review and sign: Carefully review all the information you have provided on the form. Make sure everything is accurate, complete, and understandable. Once you are satisfied, sign the form and date it. Some forms may require a witness or notary public to also sign.

Who needs release of information authorization?

1. Patients transferring healthcare providers: If you are moving to a different healthcare provider and want your medical records to be transferred, you will need to complete a release of information authorization. This ensures the new provider has access to your necessary medical information.
2. Legal and insurance purposes: When dealing with legal matters or insurance claims, you may be required to authorize the release of specific information. This allows relevant parties to access the required records for legal proceedings or insurance settlements.
3. Research or academic purposes: In certain cases, researchers or academic institutions may require access to individual's health information for research or educational purposes. A release of information authorization would be needed to grant them access.
4. Family members or caregivers: If you want your healthcare information to be shared with a family member or caregiver, an authorization form is necessary. This ensures that the person you trust has access to your medical records and can make informed decisions on your behalf.
5. Other specific circumstances: There may be other situations where the release of information authorization is required, such as for employers conducting pre-employment background checks, government agencies investigating certain cases, or individuals participating in clinical trials. It is always best to consult with the relevant authority to determine if an authorization form is necessary.

For pdfFiller’s FAQs

What is release of information authorization?

Release of information authorization is a legal document that allows an individual to give permission to disclose their personal health information to a specific person or entity.

Who is required to file release of information authorization?

The individual who owns the personal health information is required to file a release of information authorization.

How to fill out release of information authorization?

To fill out a release of information authorization, the individual must provide their personal information, specify what information can be disclosed, and sign the document.

What is the purpose of release of information authorization?

The purpose of release of information authorization is to protect an individual's privacy by controlling who has access to their personal health information.

What information must be reported on release of information authorization?

The release of information authorization must include the individual's name, date of birth, the information to be disclosed, the purpose of the disclosure, and the expiration date of the authorization.

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