Get Authorization To Disclose Information Dhs 1124 - Med Quest - Med-quest

Filling out the Authorization To Disclose Information DHS 1124 - Med Quest - Med-quest is an essential step for individuals seeking to authorize the release of their confidential information. This guide provides a clear, step-by-step approach to completing the document effectively and accurately.

Follow the steps to complete your authorization form online.

1. Use the ‘Get Form’ button to access the authorization form and open it in the designated editor.
2. In the first section, specify your name as the individual authorized to disclose information. If you are a legal representative, circle the relevant description (Applicant, Recipient, or Legal Representative), and provide a description of your authority.
3. Next, enter the name of the individual, agency, or organization that you authorize to provide your specified information.
4. In the designated space, clearly identify the specific information you wish to be disclosed. Ensure that your description is thorough and accurately reflects your needs.
5. Provide the name of the applicant or recipient in the following section, as well as their Social Security number and date of birth. Make sure this information is correct to avoid any processing delays.
6. Identify the authorized person within the Department of Human Services, Med-QUEST Division, who will receive the disclosed information, including their mailing address, city, state, zip code, and telephone number.
7. Describe the purpose for which the information will be used, ensuring this aligns with your intentions for disclosure.
8. Indicate the duration of the authorization. You can specify a date or event that will terminate the authorization, or choose to keep it valid for 90 days, whichever is sooner.
9. Sign and date the form as the applicant, recipient, or legal representative. Include your mailing address, city, state, and zip code to complete the request.
10. Finally, review the document for accuracy and completeness before you save changes, download, print, or share the form.

Complete your Authorization To Disclose Information online today for prompt processing.