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It is designed for examinees or their legal guardians to request the disclosure of raw scores and percentile rankings to a designated third-party organization. The form explicitly cites the Texas Health and Safety Code and HIPAA regulations to ensure legal compliance. It includes provisions for transmission via fax, email, or mail, establishes a 45-day validity period, and incorporates a liability waiver protecting American Mensa from legal claims arising from the authorized information release. The document also provides specific instructions for submission, requiring a witness signature and direct coordination with the Admission and Membership Coordinator to finalize the processing of the request. It acts as a formal record of informed consent for sensitive psychological data 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specific information does this form authorize to be released?","Question",{"text":112,"@type":113},"The form authorizes the release of psychological testing results, specifically raw scores and percentile rankings.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How long is this consent form valid after being signed?",{"text":117,"@type":113},"The consent is valid for 45 days from the date signed.",{"name":119,"@type":110,"acceptedAnswer":120},"Where should the completed authorization form be sent?",{"text":121,"@type":113},"Completed forms should be emailed to the American Mensa Admission and Membership Coordinator at 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, pursuant to the Texas Health and Safety Code (Sec. 576.005) and any applicable provisions of the Federal Health Insurance Portability and Accountability Act (\"HIPAA\") and the rules thereunder hereby authorize American Mensa, [Ltd. to](Ltd. to) release and disclose:  \n  Results of Psychological Testing (Raw Score and Percentile Ranking)  \nRelating to examinee,   (D/O/B:  ) to the following organization or agency:   for the purposes of review as prior evidence.  \nI request that my scores be sent via (fax, email, or mail)   to (please list fax number, address, or email address) :  \n.  \nI understand that I may revoke this consent in writing at any time.  \nThis consent is valid for 45 days from the below signed date.  \nI hereby release American Mensa, Ltd. from any and all legal liability that may arise from the release of the information requested.  \n| Signature (Legal Guardian or Examinee) |\n| --- |\n| Date |\n| Signature (Legal Guardian or Examinee)\u003Cbr>Date |\n\nSignature (Witness)  \nDate  \nPlease email completed forms to the Admission and [Membership Coordinator at Admissions@americanmensa.org](Membership Coordinator at Admissions@americanmensa.org).","cbCaibyqendoZ8C9","https://ap.wps.com/l/cbCaibyqendoZ8C9","pdf",243949,"English","# Authorization for Disclosure of Mental Health Information\n## Purpose and Legal Basis\n## Authorization and Release Details\n## Submission and Validity","[{\"question\":\"What specific information does this form authorize to be released?\",\"answer\":\"The form authorizes the release of psychological testing results, specifically raw scores and percentile rankings.\"},{\"question\":\"How long is this consent form valid after being signed?\",\"answer\":\"The consent is valid for 45 days from the date signed.\"},{\"question\":\"Where should the completed authorization form be sent?\",\"answer\":\"Completed forms should be emailed to the American Mensa Admission and Membership Coordinator at Admissions@americanmensa.org.\"}]","Test Score Release Authorization Form - American Mensa | PDF",1791050369]