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SURGICAL CARE, PC HEARTLAND SURGICAL WEIGHT LOSS CONTACT AND AUTHORIZATION FORENAME:___ EMAIL ADDRESS: ___DOB:___PERSONAL CELL PHONE: ___CONTACT: Surgical Care, PC is committed to protecting our patients

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How to fill out authorization and release contact

01

Start by identifying the purpose for which the authorization and release contact form is needed.

02

Fill out the personal information section of the form, including name, address, phone number, and date of birth.

03

Specify the contact information for the person or entity to whom you are granting authorization, including their name, address, and phone number.

04

Clearly outline the scope of authorization, detailing what information or actions the authorized party is permitted to access or undertake.

05

Sign and date the form, and ensure that it is witnessed by a third party if required.

06

Keep a copy of the completed form for your records.

Who needs authorization and release contact?

01

Individuals who wish to grant permission for someone else to access their personal information or act on their behalf may need to fill out an authorization and release contact form.

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What is authorization and release contact?

Authorization and release contact is a legal document that grants permission to use and disclose a person's personal information for a specific purpose.

Who is required to file authorization and release contact?

Any individual or organization that wishes to obtain or release personal information about a person is required to file an authorization and release contact.

How to fill out authorization and release contact?

To fill out an authorization and release contact, you must include the necessary personal information of the individual granting permission, specify the purpose for which the information will be used, and sign the document.

What is the purpose of authorization and release contact?

The purpose of authorization and release contact is to protect the privacy of individuals by ensuring that their personal information is only used for the specified purpose.

What information must be reported on authorization and release contact?

The information that must be reported on an authorization and release contact includes the name and contact information of the individual granting permission, the purpose for which the information will be used, and any limitations on the use of the information.

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