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1. Identification of Parties: Details of the record holder and the requesting party
2. Purpose of Release: Clear statement of why the records are being requested and how they will be used
3. Records Description: Specific description of which records are to be released
4. Duration of Authorization: Time period for which the release authorization is valid
5. Authorization Statement: Explicit consent for release of specified records
6. Signature Block: Space for signatures, dates, and any required witnesses
1. Revocation Rights: Statement of right to revoke authorization, used when required by applicable laws
2. Re-disclosure Notice: Warning about potential re-disclosure of information, used for HIPAA-covered records
3. Special Authorizations: Additional authorizations for sensitive information (HIV, mental health, etc.), used when such records are involved
4. Payment Notice: Information about any fees associated with records release, used when applicable
1. Records List: Detailed inventory of specific records to be released
2. Fee Schedule: Breakdown of any applicable fees for records release
3. Authorization Requirements: List of specific requirements for different types of records
Protected Information
Record Holder
Requesting Party
Authorization Period
Authorized Representative
Confidential Information
Disclosure
Re-disclosure
Protected Health Information (PHI)
Personal Information
Release Authorization
Revocation
Subject of Records
Third Party Recipient
Treatment Information
Healthcare Provider
Educational Institution
Covered Entity
Business Associate
Privacy Officer
Legal Representative
Guardian
Power of Attorney
Electronic Records
Consent
Confidentiality
Privacy
Disclosure Limitations
Duration and Expiration
Revocation Rights
Re-disclosure Restrictions
Information Access
Record Specifics
Identity Verification
Payment Terms
Liability
Indemnification
Governing Law
Signature Requirements
Electronic Transmission
Third Party Access
Security Measures
Record Delivery
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