Release Of Information Form

Release of information means the authorized person or organization can legally disclose the specific patient information, as indicated in the form, to the receiving person or organization, also specified in the form. The release of information is a specific process with a designated destination, purpose, and time-period. It does not mean that the authorized organization has no obligation to keep this information secure!

The patient or their representative can legally revoke their authorization in writing to the previously authorized agency. It’s important that they understand, however, that any disclosures already made under their initial permission cannot be undone.

This form includes a space for the patient to sign if they are authorizing the release of their own information, or for their representative to sign if they are a minor or incapable of signing themselves. The representative signature section also includes an optional space for the minor to sign, which is required in some situations for the release of a minor’s information.