Missoula County, MT · Missoula County
Authorization to Release Protected Health Information
This form lets a person authorize the release of protected health information to designated recipients for Missoula County Employee Benefits Plan purposes.
At a glance
- Issued by
- City of Missoula County · Missoula County, Missoula County, Montana
- Notarization
- Not required: file this form without a notary.
- Official source
- missoulacounty.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this authorization to permit the disclosure of protected health information to the recipients you name. The form requests identifying details, the information to be released, the recipient, the purpose, and an expiration date or event. It also explains that the authorization is voluntary and may be revoked in writing, subject to the conditions listed on the form.
Who needs it
A person authorizing the release of their protected health information to designated recipients for Missoula County Employee Benefits Plan purposes needs this form.
How to submit it
Complete and sign the form, then return it to the Risk and Benefits Office at 100 W Broadway, Missoula, MT 59802.
About notarization
This document is signed and dated without a notary; the signer just completes, signs, and dates the authorization.
How to submit this form
- 1
Download the Form
Download the Authorization to Release Protected Health Information PDF.
- 2
Complete the Authorization
Fill in the requested identifying details, information to be released, recipient, purpose, and expiration.
- 3
Sign and Date
Sign and date the authorization. The form does not require a notary.
- 4
Return It to the County
Send the completed form to the Risk and Benefits Office at 100 W Broadway, Missoula, MT 59802.
Frequently asked questions
- What does the authorization allow?
- It permits disclosure of the protected health information specified on the form to the recipients named by the signer, for the stated purpose.
- Do I need a notary for the Protected Health Information Release Authorization?
- No. The form does not require notarization; the signer completes, signs, and dates it.
- How do I submit the authorization?
- Complete and sign the form, then return it to the Risk and Benefits Office at 100 W Broadway, Missoula, MT 59802.