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Potter Henderson, M.D. Child, Adolescent & Adult Psychiatry 3772 Shore Drive, Suite 2, Virginia Beach, VA 23451 Phone: 757.708.2149 Fax: 757.644.1432Release of Information I, ___, authorize M. Potter
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How to fill out release of information17
01
Obtain a copy of the release of information form from the appropriate source.
02
Fill out your personal information, such as name, date of birth, and contact information.
03
Specify the recipient of the information, including their name, organization, and contact details.
04
List the specific information you are authorizing to be released.
05
Sign and date the form in the designated areas to confirm your consent.
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What is release of information17?
Release of Information17 is a form used to authorize the disclosure of personal information to a specific individual or entity.
Who is required to file release of information17?
Any individual or organization wishing to disclose personal information to a third party is required to file release of information17.
How to fill out release of information17?
Release of Information17 can be filled out by providing the necessary personal information of the individual authorizing the disclosure and specifying the information being released.
What is the purpose of release of information17?
The purpose of release of information17 is to ensure that personal information is disclosed only to authorized individuals or entities.
What information must be reported on release of information17?
Release of Information17 must include the name of the individual authorizing the disclosure, the recipient of the information, the purpose of disclosure, and the type of information being released.
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