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1. Parties: Identifies all relevant parties: the individual whose information will be released (the subject), the organization/person releasing the information (the discloser), and the recipient of the information
2. Background: Brief context explaining the purpose and circumstances of the information release
3. Definitions: Key terms used in the form including types of information, parties involved, and technical terms
4. Information to be Released: Specific description of the information authorized for release, including date ranges and types of records
5. Purpose of Release: Clear statement of why the information is being released and how it will be used
6. Duration of Authorization: The time period for which the release authorization is valid
7. Rights and Revocation: Statement of the subject's rights, including the right to revoke authorization and any limitations
8. Privacy Notice: Statement about how the information will be protected and any potential for redisclosure
9. Signatures and Declarations: Execution section including dates, signatures, and any witness requirements
1. Specific Authorizations: Additional authorizations for sensitive information such as mental health records, HIV status, or genetic information - used when such sensitive information may be included
2. Payment Authorization: Authorization for any fees associated with the release - used when there are costs for copying or processing records
3. Electronic Distribution Authorization: Specific consent for electronic transmission of information - used when digital transfer methods will be employed
4. Third Party Authorization: Authorization for release to additional parties beyond the primary recipient - used when information may need to be shared with multiple parties
5. Legal Representative Authorization: Additional section for when someone other than the subject is authorizing the release - used for minors or individuals lacking capacity
1. Schedule A - Record Details: Detailed list of specific records or information to be released, including dates and document types
2. Schedule B - Recipient Instructions: Specific instructions for how the information should be handled, stored, or destroyed by the recipient
3. Schedule C - Fee Schedule: If applicable, breakdown of any fees associated with the release of information
4. Appendix 1 - Proof of Identity Requirements: List of acceptable identification documents required to process the release
5. Appendix 2 - Privacy Statement: Detailed privacy notice explaining how the information will be protected and used
Sensitive Information
Health Information
Authorized Representative
Consent
Disclosure
Information Holder
Information Subject
Recipient
Release Period
Revocation
Third Party
Healthcare Provider
Medical Records
Confidential Information
Electronic Record
Identity Document
Privacy Laws
Data Controller
Processing
Re-disclosure
Witness
Guardian
Authorization Period
Capacity
Consent
Information Scope
Duration
Privacy Protection
Rights and Responsibilities
Revocation
Re-disclosure
Electronic Transmission
Fee Payment
Identity Verification
Witness Requirements
Liability
Confidentiality
Data Security
Amendments
Governing Law
Dispute Resolution
Severability
Entire Agreement
Healthcare
Education
Financial Services
Legal Services
Government
Insurance
Social Services
Professional Services
Human Resources
Real Estate
Legal
Compliance
Privacy
Medical Records
Information Management
Human Resources
Administration
Risk Management
Operations
Client Services
Information Security
Data Protection
Privacy Officer
Compliance Manager
Medical Records Administrator
Legal Counsel
Healthcare Administrator
Human Resources Manager
Data Protection Officer
Records Manager
Information Security Officer
Practice Manager
Administration Coordinator
Risk Manager
Client Services Manager
Operations Manager
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Genie’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; Genie’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it


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