1. Legal Representative Authorization: Required when someone other than the patient is providing authorization, including proof of legal authority

2. Witness Section: Used when required by healthcare facility policy or when the patient cannot sign conventionally

3. Sensitive Information Special Consent: Additional explicit consent section for sensitive medical information like HIV status, mental health records, or genetic information

4. Translation Declaration: Required when the form is explained to patient in a language other than the form's language

5. Emergency Contact Information: Optional section for including emergency contact details when relevant to the authorization purpose

1. Schedule A: Specific Records Checklist: Detailed checklist of specific medical records and document types authorized for release

2. Schedule B: Fee Schedule: List of applicable fees for medical records retrieval and copying, if any

3. Appendix 1: Proof of Identity: Requirements and acceptable forms of identification for verification

4. Appendix 2: Glossary of Medical Terms: Definitions of medical and technical terms used in the records for patient understanding