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Connecticut Travel Medicine (A Service of Mansfield Family Practice, LLC) 34 Professional Park Road Stores, Connecticut 06268 860/487/0002 860/429/1663 (fax)Today's Date: ___Date and Time of Apt:

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How to fill out authorization to release information

01

Obtain the proper authorization form from the organization or individual requesting the information.

02

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

03

Specify the type of information you are authorizing to be released.

04

Provide the details of the entity or individual you are authorizing to release the information to.

05

Sign and date the authorization form in the designated areas.

Who needs authorization to release information?

01

Anyone who wishes to disclose their personal information to a third party, such as healthcare providers, law enforcement agencies, financial institutions, or employers, needs authorization to release information.

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What is authorization to release information?

Authorization to release information is a document that gives permission to share a person's personal or medical information with specified individuals or organizations.

Who is required to file authorization to release information?

Any individual or organization seeking to share someone else's 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 of the individual giving permission, specifying the information to be shared, and identifying the recipients of the information.

What is the purpose of authorization to release information?

The purpose of authorization to release information is to protect the privacy and confidentiality of an individual's personal or medical information.

What information must be reported on authorization to release information?

Information such as the individual's name, the specific information to be shared, the purpose of sharing, and the recipients of the information must be reported on authorization to release information.

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