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AUTHORIZATION TO RELEASE WIC INFORMATION Michigan Department of Health and Human Services WIC Program Client NameFamily Client Date of Birth CodePhoneClient Address City, (Authorized Person/Participant)
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01
Fill in the individual's personal information such as name, date of birth, address, and contact information.
02
Specify the purpose for which the information is being released.
03
Indicate what specific information is authorized to be released.
04
Include the name of the individual or entity to whom the information is being released.
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Sign and date the form, and have the individual or their legal guardian also sign if applicable.

Who needs dohwagovpubs962-979-releaseofinformationindividual authorization to release?

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Healthcare providers
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Individuals seeking access to their own medical records
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It is a form used to authorize the release of an individual's information.
Individuals who want to release their information to a third party.
The form must be completed with the individual's personal information and the details of the information being released.
To legally authorize the release of an individual's information to a specific party.
Personal information of the individual and details of the information being released.
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