650-2616 Auth for Disclosure of Consumer MedicalHealth Info - dss mo-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the consumer, parent, guardian, or legal representative in the designated field at the top of the form.
3. Check all applicable boxes under the 'authorize and request' section to specify which departments or agencies are authorized to disclose information.
4. Fill in the consumer's name, date of birth, and social security number in the specified fields.
5. Indicate who will receive the disclosed information by checking relevant boxes and providing any additional names if necessary.
6. Select the purpose of disclosure by checking all that apply from the provided options.
7. Specify what specific information is to be disclosed by checking relevant items listed under 'THE SPECIFIC INFORMATION TO BE DISCLOSED'.
8. Read through the authorization terms carefully before signing. Ensure you understand your rights regarding revocation and expiration dates.
9. Sign and date where indicated. If applicable, include a witness signature as well.

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