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Authorization for Release of Information 1. Patient Information Name: Date of Birth: Maiden or other name(s): 2. I hereby request and authorize Twin Cities Pain Clinic 7235 Ohms Lane Edina, MN 55439

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For official use only is a designation indicating that certain information is restricted to authorized personnel only.

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Authorized personnel or individuals with specific clearance levels are required to file for official use only.

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The purpose of for official use only is to protect sensitive information from unauthorized access and ensure confidentiality.

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Any information that is considered confidential, sensitive, or restricted must be reported on for official use only.

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