➢. Reason or purpose for the disclosure. ➢. Date the information was disclosed.To file a Request for Review or Appeal of Assessment, the owner of the property must first submit a Letter of Authorization. Mention your name and a short description of who you are. Mention in the letter who are you authorizing to claim the money. You can find an example of a HIPAA authorization letter using Google search. One example is on the American Bar Association website. These forms may be filled out online and printed for filing. A copy of this form and a sample form are also included with this guide. 2. Fill in the 'Bank Name.