General Release Of Information Form Template for United States

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Key Requirements PROMPT example:

General Release Of Information Form

"I need a General Release Of Information Form to allow my medical provider to share my complete health records with a specialist for a second opinion, valid from January 2025 to June 2025, with specific provisions to prevent further sharing of the information."

Document background

The General Release of Information Form serves as a crucial document in various sectors where confidential information needs to be shared legally and securely. This form is designed to comply with U.S. federal and state privacy laws, including HIPAA, FERPA, and other relevant regulations. It should be used whenever protected or confidential information needs to be shared with third parties, whether for medical, educational, financial, or other purposes. The form typically includes specific details about what information can be shared, with whom, for how long, and under what conditions.

Suggested Sections

1. Parties: Identifies the party releasing information and the party/parties receiving it

2. Background: Brief context explaining why the release is needed

3. Information to be Released: Specific description of what information is authorized for release

4. Purpose: Clear statement of how the released information will be used

5. Duration: Time period for which the release is valid

6. Authorization Statement: Clear statement of consent and voluntary nature of release

7. Signature Block: Space for signatures, dates, and any required witness/notary

Optional Sections

1. HIPAA Compliance: Additional provisions required when releasing medical records or health information

2. FERPA Compliance: Additional provisions required when releasing student records or educational information

3. Financial Information Release: Specific provisions required when releasing financial or credit information

4. Electronic Disclosure Consent: Additional provisions when information will be shared electronically

5. Re-disclosure Provisions: Provisions specifying restrictions on further sharing of information

Suggested Schedules

1. Detailed Information List: Itemized list of specific records/information to be released

2. Authorized Recipients List: List of specific individuals/entities authorized to receive information

3. Special Instructions: Any specific handling or disclosure requirements

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Education
Financial Services
Insurance
Human Resources

Relevant Teams

Legal
Human Resources
Compliance
Medical Records
Information Security

Relevant Roles

Privacy Officer
Medical Records Administrator
HR Manager
Compliance Officer
Records Manager

Industries

Privacy Act 1974: Federal law establishing a code of fair information practices governing the collection, maintenance, use, and dissemination of personal information maintained by federal agencies

HIPAA: Health Insurance Portability and Accountability Act - Federal law protecting sensitive patient health information from being disclosed without patient's consent or knowledge

FERPA: Family Educational Rights and Privacy Act - Federal law protecting the privacy of student education records

FCRA: Fair Credit Reporting Act - Federal law regulating the collection, dissemination, and use of consumer credit information

GLBA: Gramm-Leach-Bliley Act - Federal law requiring financial institutions to explain their information-sharing practices and protect sensitive data

CCPA: California Consumer Privacy Act - State law providing California residents with rights regarding their personal information

State Privacy Laws: Various state-specific privacy laws that may impose additional or more stringent requirements than federal regulations

Industry Regulations: Sector-specific regulations including SEC, FINRA for financial sector, and healthcare industry standards

Identification Requirements: Legal requirement for clear identification of all parties involved in the information release

Information Specificity: Legal requirement for specific description of what information is being released

Purpose Statement: Legal requirement to clearly state the purpose for which the information will be used

Duration Specification: Legal requirement to specify how long the authorization for information release remains valid

Revocation Rights: Legal requirement to inform about the right to revoke consent and the process for doing so

Voluntary Consent: Legal requirement to include a statement confirming the voluntary nature of the release

Liability Limitations: Legal statements regarding the extent and limitations of liability for information release

Signature Requirements: Legal requirements for proper execution including signatures, dates, and any witness or notary requirements

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Authors

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