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AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATIONPatientName: Previous Name s : DOB: Phone: Address: City: State: Zip: Open Door Health Center 309 Holly Lane Mankato, MN 56001Phone: 5073882120
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What is a u t ori?
A u t ori is a form used to report certain financial information to the government.
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Certain individuals and entities are required to file a u t ori, such as financial institutions and individuals with foreign financial accounts.
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Information such as the account holder's name, address, account number, and maximum value of the account during the year must be reported on a u t ori.
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