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DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH AUTHORIZATION FOR ELECTROCONVULSIVE THERAPY (ECT) Child Name: Identification No. In accordance with Utah Rule 52385 (https://rules.utah.gov/publicat/code/r523/r523008.htm),

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To fill out form 4 authorization, follow these steps:

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Start by entering your personal information, such as your name, address, and contact details.

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Provide information about the authorized representative or organization, including their name, address, and contact details.

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Specify the purpose of the authorization and the duration for which it is valid.

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Write down the specific actions or decisions that the authorized representative is allowed to make on your behalf.

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Sign and date the form to certify that the information provided is true and accurate.

Who needs form 4 authorization for?

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Form 4 authorization is needed by individuals or organizations who wish to grant someone else the authority to act on their behalf.

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This may include situations where someone is unable to make decisions or take actions due to physical or mental incapacity, or simply prefers to delegate certain responsibilities to another person or organization.

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Common examples of those who may need form 4 authorization include individuals with disabilities, elderly individuals, or individuals who are temporarily unable to handle their own affairs.

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What is form 4 authorization for?

Form 4 authorization is for granting permission or consent for certain actions or transactions.

Who is required to file form 4 authorization for?

Individuals or entities who need authorization for specific activities or transactions.

How to fill out form 4 authorization for?

Form 4 authorization can typically be filled out by providing personal or business information and indicating the specific permission being granted.

What is the purpose of form 4 authorization for?

The purpose of form 4 authorization is to ensure that proper consent is obtained before carrying out certain actions or transactions.

What information must be reported on form 4 authorization for?

The form may require details such as name, contact information, reason for authorization, and any relevant supporting documents.

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