Form DHS-7610-ENG "Consent/Authorization for Release of Information" - Minnesota

What Is Form DHS-7610-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-7610-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-7610-ENG "Consent/Authorization for Release of Information" - Minnesota

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Clear Form
*DHS-7610-ENG*
DHS-7610-ENG
3-19
Consent/Authorization for release of information
To be completed by the person giving consent/authorization (please print):
This information is being requested solely to verify the identity of the person giving consent / authorization
Last name
First name
Date of birth
Maiden name or aliases
Current address
City
State
Zip code
Previous out of state address
City
State
Zip code
Social security number (optional)
Authorization/Consent: I authorize the
Child Abuse and Neglect Registry to release all records regarding
substantiated reports of maltreatment involving physical abuse or neglect of minors, in which I am named as the person found
responsible for maltreatment, as required by Minnesota Law.
The information will be released to:
Minnesota Department of Human Services, Background Studies Unit,
PO Box 64172, St. Paul, MN 55164-0172, (Fax #: 651-431-7670)
This information is being requested as part of a background study requirement.
Consequences: I know that state and federal privacy laws protect my records. I know:
„ Why I am being asked to release this information;
„ I do not have to consent to the release of this information, however if I do not consent, my background study will not be completed;
„ The Minnesota Department of Human Services may be able to pass along my information to the county or private agency that initiated my
background study;
„ I may stop this consent with a written notice at any time, but this written notice will not affect information the agency has already released;
„ This consent will end one year from the date I sign it, unless the law allows for a longer period.
Background study subject’s signature
Parent / guardian signature (subject is a minor)
Date
Date
PO Box 64172 * Saint Paul, Minnesota * 55164-0172 * An Equal Opportunity Employer
http://mn.gov/dhs/background-studies
Clear Form
*DHS-7610-ENG*
DHS-7610-ENG
3-19
Consent/Authorization for release of information
To be completed by the person giving consent/authorization (please print):
This information is being requested solely to verify the identity of the person giving consent / authorization
Last name
First name
Date of birth
Maiden name or aliases
Current address
City
State
Zip code
Previous out of state address
City
State
Zip code
Social security number (optional)
Authorization/Consent: I authorize the
Child Abuse and Neglect Registry to release all records regarding
substantiated reports of maltreatment involving physical abuse or neglect of minors, in which I am named as the person found
responsible for maltreatment, as required by Minnesota Law.
The information will be released to:
Minnesota Department of Human Services, Background Studies Unit,
PO Box 64172, St. Paul, MN 55164-0172, (Fax #: 651-431-7670)
This information is being requested as part of a background study requirement.
Consequences: I know that state and federal privacy laws protect my records. I know:
„ Why I am being asked to release this information;
„ I do not have to consent to the release of this information, however if I do not consent, my background study will not be completed;
„ The Minnesota Department of Human Services may be able to pass along my information to the county or private agency that initiated my
background study;
„ I may stop this consent with a written notice at any time, but this written notice will not affect information the agency has already released;
„ This consent will end one year from the date I sign it, unless the law allows for a longer period.
Background study subject’s signature
Parent / guardian signature (subject is a minor)
Date
Date
PO Box 64172 * Saint Paul, Minnesota * 55164-0172 * An Equal Opportunity Employer
http://mn.gov/dhs/background-studies