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MENTAL HEALTH CENTER OF EAST CENTRAL KANSAS
1000 Lincoln Emporia, KS 66801 Phone: 800 2793645 Fax: 620 3421021
Authorization for the Disclosure of Protected Health Information
Including Mental Health
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How to fill out universal release form 1105docx
01
To fill out the universal release form 1105docx, follow these steps:
1. Open the form in a compatible document editor such as Microsoft Word.
02
Read the instructions at the beginning of the form to understand its purpose and usage.
03
Provide your personal information in the designated fields, including your full name, address, phone number, and email.
04
Specify the date on which you are filling out the form.
05
If applicable, indicate the organization or entity you are releasing from any liability.
06
Review the release statements carefully and ensure you understand their implications.
07
Sign the form with your full legal signature, indicating your consent to release.
08
If required, have a witness sign the form as well.
09
If necessary, provide any additional information or details requested in the form.
10
Once you have completed filling out the form, save it and make copies for your records.
11
Submit the filled-out form as instructed by the recipient or organization requiring the release.
Who needs universal release form 1105docx?
01
Anyone who wishes to release an organization or entity from liability may need the universal release form 1105docx. This form is typically used in legal contexts where a person voluntarily waives their rights to hold the organization accountable for any damages, injuries, or liabilities that may arise. Common scenarios where this form may be necessary include participation in activities with inherent risks, granting permission for the use of personal or copyrighted materials, or entering into contractual agreements where the release of liability is required.
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