Release Of Information Form Template for United States

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Key Requirements PROMPT example:

Release Of Information Form

"I need a Release of Information Form to allow my current healthcare provider to share my medical records with a specialist for a second opinion, ensuring all mental health records from the past three years are included and the authorization expires on June 15, 2025."

Document background

The Release of Information Form serves as a critical document in maintaining privacy compliance while facilitating necessary information sharing. This document is essential when any confidential information needs to be shared between authorized parties, particularly in healthcare, educational, or legal contexts. The form must comply with HIPAA regulations, state privacy laws, and other relevant federal legislation in the United States. It typically includes specific details about the information being released, the purpose of the release, time limitations, and the rights of the information owner. The Release of Information Form is designed to protect both the information owner's privacy rights and the releasing organization's legal compliance.

Suggested Sections

1. Patient Information: Basic identifying information about the patient including name, date of birth, address, and contact details

2. Information to be Released: Specific description of what information is authorized for release, including type of records, date ranges, and any specific exclusions

3. Purpose of Release: Stated reason for releasing the information (e.g., continued care, legal purposes, insurance, personal records)

4. Authorization Period: Timeframe during which the release is valid, including start date and expiration date

5. Rights Statement: Description of patient rights including right to revoke authorization, right to inspect records, and any limitations

6. Signature Block: Space for signatures, dates, and witness information, including patient or legal representative authorization

Optional Sections

1. Special Authorization: Additional authorization requirements for sensitive information such as HIV status, mental health records, or substance abuse treatment

2. Re-disclosure Notice: Statement about potential re-disclosure of information and limitations on protection once information is released

3. Electronic Transmission Authorization: Specific permission for electronic sharing of information including fax, email, or other digital formats

Suggested Schedules

1. Records Index: Detailed list of specific records being released, including dates and types of documentation

2. State-Specific Addendum: Additional requirements and disclosures based on applicable state laws

3. Fee Schedule: Outline of any costs associated with records release and copying fees if applicable

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Education
Insurance
Legal Services
Social Services

Relevant Teams

Medical Records
Legal
Compliance
Administrative Services
Privacy Office

Relevant Roles

Medical Records Administrator
Privacy Officer
Healthcare Administrator
Compliance Officer
Legal Counsel

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Written Authorization Form

A U.S. legal document that formally grants specific permissions or authority from one party to another.

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Authors

Alex Denne

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