Blank Authorization To Release Information Form

Learn how a Blank Authorization To Release Information Form helps protect patient privacy. Download a PDF template and example today!

By Ericka Pingol on Jul 15, 2024.


Fact Checked by RJ Gumban.

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Blank Authorization To Release Information Form PDF Example
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What is a release of information form?

A release of information form, also known as an authorization to release information form, is a crucial document in healthcare settings related to a HIPAA release form. This form allows patients to give consent for healthcare providers to share their protected health information (PHI) with specified individuals or organizations.

This form's primary purpose is to ensure patient privacy while facilitating the necessary sharing of medical information. It's a legal safeguard that complies with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which sets national standards for protecting individuals' medical records and other personal health information.

Check out this video on our HIPAA Authorization Form to see how these resources can be accessed and used:

Blank Authorization To Release Information Form Template

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Blank Authorization To Release Information Form Example

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What should be included in a medical release form?

When preparing or reviewing a consent to release information form, ensure it includes these essential elements:

  1. Patient information: Full name, date of birth, and contact details.
  2. Provider information: Name and address the healthcare provider or entity releasing the information.
  3. Recipient information: Name and address of the person or entity receiving the information.
  4. Description of information to be released: Specific medical records or data to be disclosed.
  5. Purpose of disclosure: Reason for releasing the information (e.g., continued care, insurance claims, legal purposes, transferring medical records).
  6. Expiration date: The time period for which the authorization remains valid.
  7. Patient signature and date: Confirmation of the patient's consent.
  8. Statements of rights: Information about the patient's right to revoke the authorization and potential for re-disclosure.

How to use this Blank Authorization to Release Information Form

We have developed a printable release medical information form that can be an alternative to the HIPAA Release Form. This form is designed to facilitate the creation of a legally binding document for you and your patients when undertaking healthcare operations. Follow these steps to get started:

Step 1: Access the form

You can download our Blank Authorization to Release Information Form from the link provided on this page. Alternatively, you may access it through the Carepatron app or our resources library.

Step 2: Explain the form to your patient

Take the time to explain to your patient that by completing this form, they are providing valid authorization for you to disclose their protected health information. Ensure that they clearly understand the form's purpose and the rights they have regarding their data.

Step 3: Patient completes the necessary details

Ask your patient to complete all the required information on the form, including their name, address, and contact details. Then, request your patient to provide the purpose for releasing the information, specify the details they wish to disclose, and indicate the duration of their authorization.

Step 4: Ask the patient to sign the form

Your patient must sign the form to establish its legal validity. Once they have done this, you may proceed with the release. Also, ask the witness to sign the template to verify the document's authenticity.

Step 5: Keep a copy for your records

It is important to keep a copy of the form in your patient's chart for legal and documentation purposes. This will provide evidence that your patient has granted their permission for the disclosure.

When would you use this Template?

You can utilize this Blank Authorization to Release Information Form to assist your patients in granting consent for disclosing their protected health information to themselves or third parties. You can also use this template to:

Obtain explicit consent from patients before disclosing medical information

Using this Blank Authorization to Release Information Form, you can ensure that patients provide written consent before sharing their personal health information. This proactive approach helps protect you and your patients in case of any legal disputes concerning data breaches or unauthorized access.

Demonstrate adherence to HIPAA regulations

The form is tangible evidence of your compliance with privacy guidelines, including those outlined by HIPAA. It reinforces your commitment to maintaining the security and confidentiality of PHI. Keeping a duly signed Blank Authorization to Release Information Form on record is a valuable indicator of your adherence to these regulations.

Document the authorized release of confidential patient data

The Blank Authorization to Release Information Form provides a documented record of a patient's authorization to disclose confidential data, as mandated by HIPAA regulations. This documentation acts as a protective measure, mitigating the potential for legal action if the decision to share PHI with external entities or individuals is contested.

Safeguard your practice from legal repercussions and privacy violations

Utilizing this template helps protect your practice against potential legal consequences or privacy breaches stemming from the unauthorized release of confidential patient information. This is especially crucial for practices dealing with significant amounts of PHI regularly.

Who can use this free Blank Authorization to Release Information Form PDF?

Our free template is designed for use by healthcare providers, including:

  • Doctors
  • Dentists
  • Therapists
  • Physical therapists
  • Social workers
  • Counselors
  • Nurses
  • Occupational therapists

Hospitals and other organizations handling protected health information can use this form to maintain compliance with HIPAA regulations. Moreover, insurance companies, attorneys, and other third-party entities seeking access to confidential medical information can benefit from it.

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What is an authorization to release information form?
What is an authorization to release information form?

Commonly asked questions

What is an authorization to release information form?

An authorization to release information form is a document that allows a healthcare provider to share a patient's protected health information (PHI) with a designated third party, such as another medical provider, a personal representative, or a family member. This form specifies what information can be shared, the purpose of the disclosure, and the time period the authorization is valid.

Does a HIPAA release form need to be notarized?

No, a HIPAA release form does not need to be notarized. HIPAA does not require notarizing these forms, though some healthcare organizations may choose to have them notarized as an additional security measure.

What are the requirements of a valid authorization to release information?

A valid authorization form to release information must include the patient's signature, the specific information to be disclosed, the person/entity authorized to make the disclosure, the person/entity authorized to receive the information, the purpose of the disclosure, an expiration date or event, and a statement that the patient has the right to revoke the authorization. The form must be written in plain language that the patient can understand.

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