Fill - Free fillable Consent for Release of Information (Hennepin County) PDF form

Staff use only

This form must be completed, signed and submitted when someone requests private data on an individual

(data subject) and the county needs the data subject’s permission.

Consent for Release of Information

Data subject

Full name:

Aliases, nicknames, previous or maiden names:

Date of birth:

Phone:

Address:

Email:

If data subject is a minor or a legally incompetent adult

Parent or legal guardian full name:

Relationship to data subject:

Recipient

I (data subject) authorize Hennepin County to release information or records about me to

Name of organization:

Name of person:

Address:

Phone:

Request

Release the following information or records

Authorization

 I am the data subject, or the parent or legal guardian of a data subject who is a minor, or

the legal guardian of a legally incompetent adult

 I declare I have examined all the information on this form and it is true and correct to the

best of my knowledge

 This authorization is valid for one (1) year from the signed date of this form. I understand I

can cancel this authorization at any time.

Signature

Data subject or parent/legal guardian signature

Data subject or parent/legal guardian printed name

Date signed

Tennessen Notice

If you are requesting data about yourself that is private, the information you provide to the

county related to the data request, including your name, may be considered private data. You

are not required to provide us with private data; however, if you do not provide us with some

private data (e.g. date of birth) we may not be able to process your request. Any private data

you provide to us may be shared with other data practices contacts in Hennepin County to

Fill Online, Printable, Fillable, Blank Consent for Release of Information (Hennepin County) Form