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CHILDLINE AND ABUSE REGISTRY P.O. BOX 8170 HARRISBURG, PENNSYLVANIA 171058170CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATIONI, ___, hereby
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Obtain a copy of the consentrelease of information form.
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Read the instructions on the form carefully.
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Fill in all required fields, including your personal information and the information of the party you are authorizing to release information to.
04
Specify the type of information you are authorizing to be released.
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Sign and date the form.

Who needs consentrelease of information?

01
Individuals who want to authorize the release of their personal information to a specific party or organization.
02
Healthcare providers who need to obtain consent to release patient information.
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Consent release of information is a form or document that allows an individual to authorize the disclosure of their personal information to a third party.
Any individual or organization that needs to share personal information with a third party is required to file a consent release of information.
To fill out a consent release of information, the individual must provide their personal details, identify the recipient of the information, specify the type of information being shared, and sign the document to authorize the disclosure.
The purpose of consent release of information is to protect the privacy rights of individuals by ensuring that their personal information is disclosed only with their consent.
The information reported on a consent release of information typically includes the individual's name, contact details, the purpose of the disclosure, and the type of information being shared.
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