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FH-CL-008 • VERSION 1.0
Communication & Information Release Authorization
Communication preferences and authorized people or organizations.
Digital workflow:
Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.
1. Record identification
Client name *
Date *
Completed by *
2. Preferences & permissions
Preferred methods
Phone
Text
Email
Mail
In person
Voicemail permitted
Authorized person #1
Authorized person #2
Authorized organizations / providers
Do-not-contact names / restrictions
Information categories authorized
Billing and caregiver communication limits
Authorization effective / expiration dates
3. Certification / acknowledgment
Electronic signature / typed name *
Signature date *
Notes
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