Sample Authorization To Release Information Form

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SAMPLE AUTHORIZATION TO RELEASE INFORMATION FORM
[Name and Address of Your Organization]
Authorization to Release Information
Consumer’s Name:
Date of Birth:
Consumer’s Social Security Number:
I hereby authorize [Name of Your Organization] to (check one):
_____ obtain from the following
_____ release to the following
Name:
Address:
the following documents/information from the records pertaining to services received
Date of Service:
The documents to be released are described or listed as:
The records are required for the specific purpose of:
I understand that my authorization will remain effective from the date of my signature until
, and that the information will be handled confidentially in compliance with
all applicable federal laws.
I understand that I may see the information that is to be sent, and that I may revoke the authorization
at any time by written, dated communication.
I have read and understand the nature of this release.
___________________________________________________
____________________
Signature of Consumer/Consumer’s Designated Representative
Date
___________________________________________________
____________________
Witness
Date

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