Get the free Release of Information - Healing Moments Counseling
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Healing Moments Counseling LLC
9766 Fallon Ave Suite 201
Monticello, MN 55362
Phone (763) 7323351 Fax (763) 3225026Authorization to Release Protected Information!! Patient Name(please print)!
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How to fill out release of information
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To fill out a release of information form, follow these steps:
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Specify the purpose of the release by stating the name of the organization or individual who will be receiving the information.
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Indicate the type of information you want to release, such as medical records, employment records, or educational records.
05
Clearly state the dates or time period for which the information should be released.
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State any specific limitations or conditions for the release of information, if applicable.
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Sign and date the form to authorize the release of information.
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Note: It's important to read and understand the terms and conditions mentioned on the form before filling it out.
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