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AUTHORIZATION TO DISCLOSE INFORMATIONClear FieldsNORTH DAKOTA DEPARTMENT OF HUMAN SERVICES LEGAL SERVICES SON 1059 (92019)PRIVACY STATEMENT: Disclosure of the social security number is voluntary and

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Fill out your personal information such as name, address, date of birth, etc.

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Individuals who want to authorize the disclosure of their personal information to a third party.

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What is fillioauthorization-to-disclose-informationfill - authorization to?

Authorization to disclose information to a specified individual or entity.

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The individual or entity seeking access to the disclosed information must file the authorization form.

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The form must be completed with the required information about the requesting party and the information being disclosed.

What is the purpose of fillioauthorization-to-disclose-informationfill - authorization to?

To grant permission for the disclosure of specific information to a designated recipient.

What information must be reported on fillioauthorization-to-disclose-informationfill - authorization to?

The type of information being disclosed, the purpose of the disclosure, and the recipient of the information.

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