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Release of Information Form Template

Streamline your information sharing with ease

Trying to navigate the complexities of information sharing can be overwhelming, especially when ensuring compliance and client privacy. This Release of Information Form Template is designed to help healthcare providers and organizations like yours facilitate the smooth transfer of vital patient information, ensuring transparency and efficiency. By utilizing this template, you can reduce paperwork errors, enhance patient consent management, and maintain compliance with regulations like HIPAA. Plus, it features WCAG-aligned labels for accessibility, making it usable for everyone. Explore how you can effortlessly create a clear and concise release of information today!

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Patient full name
If not the patient, describe your legal authority
Patient date of birth
Patient address
Patient phone number
Patient email address
Your role in relation to the patient
Patient
Parent or legal guardian
Healthcare power of attorney
Other authorized representative
Name of organization or provider authorized to release information
Name or organization authorized to receive the information
Recipient delivery details (email, fax, or mailing address)
Preferred delivery method
Secure email
Fax
Mail
In-person pickup
Select the information to be released
If Other, describe the information to be released
Records date range start
Records date range end
Include any sensitive information (select all that apply)
Authorization expiration date
Purpose of the disclosure
Continuity of care
Personal use
Insurance or claims
Legal matter
Employment
School
Research
Other
Please Specify:
I authorize the release of the information as specified above
Yes
No
I understand I may revoke this authorization in writing at any time
Yes
No
I understand information disclosed may be redisclosed by the recipient and may no longer be protected by HIPAA
Yes
No
Name of person authorizing the release
Signature of person authorizing the release (type full legal name)
Date signed
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Paper art illustration related to Release of Information Form Template and FormCreatorAI features design elements and text.

When to use this form

Use this form when you need written consent to share a persons records with another party. Healthcare teams can send charts to a specialist, insurer, or employer after treatment. Schools and camps may request health records before a trip or program. HR can verify immunizations or test outcomes during hiring. It also helps public agencies coordinate services across providers. If you are transferring lab results, pair the authorization with the COVID-19 Lab report form. For screenings tied to employment or immigration, you may reference the TB Skin test results form. When travel rules apply, include a Travel declaration form. With clear scope and dates, you reduce delays, protect privacy, and document exactly what is shared.

Must Ask Release of Information Questions

  1. Whose records are you authorizing to release (full name, date of birth, and ID)?

    This confirms you have the right person and prevents a mix-up with similar names. Including identifiers helps staff find the correct file fast.

  2. Who is authorized to receive the information (recipient name, organization, and contact)?

    Clear recipient details ensure records go only to the intended party. It also provides the delivery info your team needs to send securely.

  3. What specific information and date range may be disclosed?

    Listing the exact documents and timeframe limits what is shared and reduces risk. It helps staff retrieve only what the recipient needs.

  4. What is the purpose of the disclosure, and when does it expire?

    Stating why you are sharing guides the minimum necessary scope (for example, travel screening supported by a Coronavirus-19 health declaration form). An expiration date sets a clear end to consent and prevents open-ended access.

  5. Do you acknowledge and sign to authorize this release (signature, date, and relationship, if not the subject)?

    A signature makes the authorization valid and auditable. Dating the form shows when consent was given and who provided it.

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