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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."

What is a Release Of Information Form?

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.

What sections should be included in a Release Of Information Form?

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

What sections are optional to include in a Release Of Information Form?

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

What schedules should be included in a Release Of Information Form?

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) @ ¶¶ÒõÊÓÆµ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Clauses




















Industries

HIPAA: Health Insurance Portability and Accountability Act of 1996 - Includes Privacy Rule requirements, Security Rule requirements, patient rights regarding their health information, and requirements for valid authorization

FERPA: Family Educational Rights and Privacy Act - Governs educational records privacy, student privacy rights, and parent/guardian access rights

State Privacy Laws: State-specific privacy protection laws, medical records requirements, mental health records regulations, and special protections for sensitive information (HIV, substance abuse, etc.)

42 CFR Part 2: Federal regulations providing specific requirements for substance abuse treatment records and additional privacy protections

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Covers electronic health records requirements and security breach notification requirements

ADA: Americans with Disabilities Act - Includes confidentiality requirements for medical information and workplace accommodations information

Required Form Elements: Essential components including purpose of release, specific information to be released, who can release/receive information, expiration date/event, right to revoke, statement of understanding, notice of re-disclosure, and signature requirements

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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