Fillable Authorization For Release Of Information Form printable pdf download

Authorization for Release of Information

This form is to be completed by the applicant with the name(s) of any other individual(s) or entity(s), besides the applicant,

that the applicant would allow this Board to discuss the status of the pending application, i.e. spouse, staff member, etc,

and returned with the application. Without this completed form, the Board may only discuss the pending status with

the applicant.

⁪

I will be the only individual inquiring about the status of my application. If you are not authorizing the release of

information to a third party, you will not need to have this form notarized, just sign and date below.

⁪

I authorize the following individuals to inquire about the status of my application (see below):

________________________________________________________________________________

First Name

Last Name

Relationship to Applicant

________________________________________________________________________________

Name of Entity (University, Hospital, etc)

______________________________________ __________________________________________

Telephone Number

Email Address

________________________________________________________________________________

First Name

Last Name

Relationship to Applicant

________________________________________________________________________________

Name of Entity (University, Hospital, etc)

_____________________________________ ___________________________________________

Telephone Number

Email Address

I hereby authorize and direct the Idaho State Board of Medicine, employees, agents, officers, representatives,

and attorneys at any time to release information regarding my filed application for an Idaho license and/or permit with the

Idaho State Board of Medicine to the individuals named above.

I further authorize the Idaho State Board of Medicine, employees, agents, officers, representatives, and attorneys

who have such information to consult with or discuss such information with any of the individuals named above.

Upon my knowledge and with legal consultation, I understand the nature of this Authorization for Release of

Information with regard to my filed application for an Idaho license and/or permit with the Idaho State Board of Medicine.

I, and my heirs, do hereby release the Idaho State Board of Medicine, Committee on Professional Discipline of

the Idaho State Board of Medicine, and its members, employees, agents, officers, representatives, and attorneys, from all

liability and all claims of any nature whatsoever pertinent to the information released.

Name of Applicant: ________________________________________________________________________

(First, Middle, Last)

Signature: _________________________________________________________ Date: _________________

State of: ____________________

:ss

County of: __________________

On this ____ day of __________________, 20____, before me, the undersigned, a Notary Public in and for said State,

personally appeared ______________________________________, known or identified to me to be the person whose

name is subscribed to the within instrument, and acknowledged to me that he/she executed the same.

I WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal the day and year in this certificate first

above written.

__________________________________________________

____________________________

Notary Public for

________________________________

Residing at:

_______________________

My commission expires:

Authorization For Release Of Information Form

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