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Consent to Release Information
A statement that the information disclosed may be subject to re-disclosure by the recipient. (Numbers 7, 8, and 9 are included in the text of our standard form).
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Model Template Agency Release of Information Form
If, after fully considering the risks and benefits, you decide you want [Program/Agency Name] to release some of your confidential information, use this form to
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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH
Directions: Type or Print all requested information, with exception of signatures on Page 2. Individuals Name (Beneficiary, Recipient, Patient, Consumer, etc.).
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