1. Specific Exclusions: Section to explicitly state any parts of the medical record that should NOT be released - used when patient wants to withhold specific information

2. Mental Health Records Authorization: Additional authorization specifically for mental health records - required when mental health records are included

3. Representative Authority: Section establishing the authority of a representative to act on behalf of the patient - used when someone other than the patient is authorizing release

4. Electronic Transfer Authorization: Specific authorization for electronic transfer of records - used when records will be transmitted electronically

5. Fees and Charges: Information about any costs associated with the release of records - used when the provider charges for record copying/transfer

1. Schedule 1 - Types of Medical Records: Detailed checklist of specific types of medical records that may be released (e.g., lab results, imaging reports, consultation notes)

2. Schedule 2 - Authorized Recipients List: List of all authorized recipients when multiple parties are authorized to receive the records

3. Appendix A - Glossary: Definitions of medical and legal terms used in the form

4. Appendix B - Privacy Statement: Detailed privacy statement explaining how the information will be handled and protected