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DISUSED 45
Rev. 01/2018State of Utah
Department of Workforce Services
Utah State Office of Rehabilitation (USER)
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)This authorization form
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How to fill out this authorization form has
How to fill out this authorization form has
01
Start by reading the instructions provided on the form.
02
Fill in your personal information such as name, address, and contact details.
03
Provide the details of the person or organization you are authorizing.
04
Specify the actions or decisions that you are authorizing the other party to take on your behalf.
05
Sign and date the form to make it legally binding.
06
Make a copy of the completed form for your records.
Who needs this authorization form has?
01
Anyone who wants to authorize another person or entity to act on their behalf
02
Individuals who are unable to make decisions for themselves
03
Legal guardians of minors or incapacitated individuals
04
Business owners who want to authorize employees to make decisions on their behalf
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What is this authorization form has?
This authorization form allows an individual to grant permission to another person or entity to act on their behalf in a specific matter.
Who is required to file this authorization form has?
Any individual who is granting authorization to someone else to act on their behalf in a specific matter is required to file this form.
How to fill out this authorization form has?
The form must be filled out completely and accurately, including all required information such as name, contact details, the matter or action being authorized, and any limitations placed on the authorization.
What is the purpose of this authorization form has?
The purpose of this authorization form is to legally allow someone else to represent or act on behalf of an individual in a specific matter.
What information must be reported on this authorization form has?
The form must include the name and contact details of both the individual granting authorization and the person or entity receiving authorization, as well as details of the specific matter or action being authorized.
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