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Form F1E: Authorization to Release Substance Abuse Treatment
Records Following Termination of Coverage
INSTRUCTIONS: You must complete all information below. If incomplete, this authorization will
be
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How to fill out authorization to release information
How to fill out authorization to release information
01
To fill out an authorization to release information, follow these steps:
02
Write your full name and contact information at the top of the form.
03
Specify the purpose of the authorization (e.g., medical records release, employment verification).
04
Identify the recipient or organization who will be receiving the information.
05
Specify the type of information you are authorizing to be released (e.g., medical records, educational records).
06
Include the dates or timeframe for which the authorization is valid.
07
Sign and date the authorization form.
08
If applicable, provide any additional instructions or conditions.
09
Keep a copy of the completed authorization form for your records.
Who needs authorization to release information?
01
Various entities or individuals may need authorization to release information, including:
02
- Healthcare providers or hospitals
03
- Educational institutions
04
- Employers
05
- Government agencies
06
- Legal representatives
07
- Insurance companies
08
- Banks or financial institutions
09
- Social service organizations
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