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AUTHORIZATION FOR RELEASE AND/OR DISCLOSURE OF MEDICAL INFORMATION Please REQUEST medical information FROM (the Sending Provider):Please SEND medical information TO (the Receiving Provider):Clinic/Physician:
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Authorization for release request is a formal permission allowing a designated individual or entity to access or obtain specific information or records.
Typically, the individual whose information is being requested or a legal representative acting on their behalf is required to file the authorization for release request.
To fill out the authorization for release request, you need to provide pertinent details such as the name of the person granting authorization, the name of the entity receiving the information, specific information to be released, and signatures from all parties involved.
The purpose of the authorization for release request is to ensure that personal information is only disclosed with the consent of the individual, thereby protecting privacy and complying with legal regulations.
Information that must be reported includes the full name and contact information of the person granting authorization, the recipient's information, the type of information to be released, and the date of signature.
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