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Mr. Robert AngeliSuperintendent of Schoolsrangeli@killinglyschools.orgSue NashDitzelAssistant Superintendentsnash@killinglyschools.orgAUTHORIZATION TO RELEASE RECORDS NAME:GRADE:___ D. O B.___NAME:GRADE:___

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How to fill out authorization to release records

01

Obtain the authorization to release records form from the organization or healthcare provider.

02

Fill out your personal information, including your full name, date of birth, and contact information.

03

Specify the records you are authorizing to be released by providing details such as the type of records, dates, and any specific information needed.

04

Sign and date the form to confirm your consent to release the records.

05

If the authorization needs to be sent to a specific recipient, make sure to include their contact information as well.

06

Return the completed form to the organization or healthcare provider through the designated method (e.g., in person, by mail, or through an online portal).

Who needs authorization to release records?

01

Anyone who wants their records released to a third party such as another healthcare provider, insurance company, legal representative, or government agency.

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What is authorization to release records?

Authorization to release records is a legal document that allows a healthcare provider to disclose a patient's medical information to a third party.

Who is required to file authorization to release records?

The patient or their legal guardian is required to file authorization to release records in order for the healthcare provider to disclose the medical information.

How to fill out authorization to release records?

To fill out authorization to release records, the patient must provide their name, date of birth, the name of the healthcare provider, the information to be disclosed, and the name of the person or entity receiving the information.

What is the purpose of authorization to release records?

The purpose of authorization to release records is to protect the privacy of the patient's medical information and ensure that it is only disclosed to authorized individuals or entities.

What information must be reported on authorization to release records?

The authorization to release records must include the patient's name, date of birth, the specific information to be disclosed, the name of the healthcare provider, and the name of the person or entity receiving the information.

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