Authorization To Disclose Information (Medical) | Pdf Fpdf Doc Docx | New Jersey

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Authorization To Disclose Information (Medical) | Pdf Fpdf Doc Docx | New Jersey

Last updated: 8/5/2022

Authorization To Disclose Information (Medical)

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Description

AUTHORIZATION TO DISCLOSE INFORMATION. This form is used in the New Jersey Department of Human Services to give written permission for the department to share personal information with a specified individual or organization. This form allows individuals to authorize the release of their information, including medical records or other personal details, to a third party. The form includes sections to specify who the information is to be disclosed to, what information will be shared, and the duration of the authorization. It also outlines the individual's rights to revoke the authorization and the potential risks associated with the re-disclosure of the information. If substance abuse information is being disclosed, the purpose for the disclosure must be stated. The form must be signed and dated by the individual or their representative. www.FormsWorkflow.com

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