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AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION This is the only release accepted by IMS Health Disability Evaluation ServicesAPPLICANT: If you do not fully fill out this Authorization to Release

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- Fill in the personal information section, including your name, address, and contact details

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Anyone who wishes to authorize the release of their personal information to a specific person or organization needs to fill out the www.mass.gov/doc/authorization-to-release form. This may include individuals who are seeking to share medical records with a healthcare provider, providing financial information to a bank or lender, granting access to academic records to an educational institution, or any other situation where written authorization is required.

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What is www.mass.gov/doc/authorization-to-release? This form only?

The form at www.mass.gov/doc/authorization-to-release is used only for authorizing the release of specific information or records.

Who is required to file www.mass.gov/doc/authorization-to-release? This form only?

Individuals who want to authorize the release of their information or records are required to file this form.

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To fill out the form, individuals must provide their personal information, specify the information or records to be released, and sign the authorization.

What is the purpose of www.mass.gov/doc/authorization-to-release? This form only?

The purpose of this form is to allow individuals to grant permission for the release of their specific information or records to a designated party.

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The form requires individuals to specify the type of information or records they are authorizing to be released, along with their personal details.

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