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AUTHORIZATION TO RELEASE INFORMATIONHealth Information Services 200 University Ave. E. St. Paul, MN 55101 Phone: 6513123122 Fax: 65122938881. You must clearly complete all items in this document marked

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How to fill out authorization to release information

01

Clearly state your name, date of birth, and address at the beginning of the form.

02

Specify the individual or organization you are authorizing to release information.

03

Include detailed information about the specific information that can be released.

04

State the purpose of the release of information.

05

Sign and date the form to indicate your consent.

Who needs authorization to release information?

01

Individuals or organizations who require access to confidential information about a person, such as healthcare providers, insurance companies, legal representatives, or government agencies, need authorization to release information.

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What is authorization to release information?

Authorization to release information is a document that allows a designated individual or organization to disclose specific information about a person to a third party.

Who is required to file authorization to release information?

Anyone who wishes to share their personal information with a third party or give permission for someone else to access their information is required to file authorization to release information.

How to fill out authorization to release information?

Authorization to release information can be filled out by providing personal details, specifying the information that can be disclosed, and signing the document to grant permission.

What is the purpose of authorization to release information?

The purpose of authorization to release information is to protect an individual's privacy by ensuring that their information is only shared with specific parties with proper consent.

What information must be reported on authorization to release information?

Information such as the name of the individual authorizing the release of information, the recipient of the information, the type of information being disclosed, and the purpose of the disclosure must be reported on authorization to release information.

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