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DHS119 (E) 09/29/2022 (page 1 of 2) Record Release Authorization Form I am requesting: Shelter History Letter Copy of my Case RecordsName: ___ Date of Birth: ___ SSN:___ CARES ID: ___ I hereby authorize

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How to fill out record release authorization form

01

Obtain the record release authorization form from the organization or medical facility

02

Fill in your personal information such as name, address, date of birth, and contact information

03

Specify the records you are authorizing to be released and the purpose of the request

04

Sign and date the form to certify that you are authorizing the release of the specified records

Who needs record release authorization form?

01

Anyone who needs to authorize the release of their records to a third party such as a healthcare provider, insurance company, or legal representative

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What is record release authorization form?

Record release authorization form is a document that allows an individual or organization to release specific records to another party.

Who is required to file record release authorization form?

The individual or organization that wants to release records to another party is required to file the record release authorization form.

How to fill out record release authorization form?

To fill out a record release authorization form, one must provide all necessary information requested on the form, including details of the records to be released and the recipient of the records.

What is the purpose of record release authorization form?

The purpose of record release authorization form is to authorize the release of specific records to a designated party.

What information must be reported on record release authorization form?

The information that must be reported on a record release authorization form includes details of the records to be released, the reason for the release, and the recipient of the records.

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