Authorization For Disclosure Of Medical Information for the United States

Authorization For Disclosure Of Medical Information Template for United States

A legally binding document compliant with HIPAA and state-specific regulations in the United States, which authorizes the release of an individual's protected health information from one party to another. The document specifies what information can be shared, with whom, for what purpose, and for how long the authorization remains valid. It includes mandatory elements required by federal and state laws to ensure patient privacy protection and informed consent.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our United States-compliant Authorization For Disclosure Of Medical Information

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Authorization For Disclosure Of Medical Information

Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

Upload your Doc

What is a Authorization For Disclosure Of Medical Information?

The Authorization For Disclosure Of Medical Information is a crucial document required under U.S. federal and state privacy laws whenever protected health information needs to be shared with parties other than the original healthcare provider. This document ensures compliance with HIPAA regulations and provides a standardized way to obtain patient consent for information sharing. It's commonly used in situations involving insurance claims, continuing care, legal proceedings, or when patients want to share their medical information with family members or other healthcare providers. The authorization must specify the information to be shared, intended recipients, purpose, and duration of the authorization.

What sections should be included in a Authorization For Disclosure Of Medical Information?

1. Patient Information: Full name, date of birth, address, and contact information of the patient

2. Healthcare Provider Information: Details of the provider/facility authorized to release the information

3. Recipient Information: Details of the person/entity authorized to receive the information

4. Information to be Disclosed: Specific description of medical information to be released

5. Duration: Expiration date or event for the authorization

6. Rights Statement: Patient's rights including right to revoke and refuse to sign

7. Signatures: Patient/legal representative signature block with date

What sections are optional to include in a Authorization For Disclosure Of Medical Information?

1. Special Categories Authorization: Additional authorization for sensitive information such as mental health records, HIV status, substance abuse treatment, or genetic information

2. Purpose of Disclosure: Specific reason for the information release, used when tracking or limiting the use of disclosed information

3. Electronic Delivery Authorization: Permission for electronic transmission of records when digital delivery is requested

What schedules should be included in a Authorization For Disclosure Of Medical Information?

1. Detailed Medical Record List: Itemized list of specific records to be disclosed

2. State-Specific Addendum: Additional provisions required by specific states' laws and regulations

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

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Insurance
Legal Services
Research Institutions

Relevant Teams

Medical Records
Legal
Compliance
Privacy Office
Administration

Relevant Roles

Medical Records Administrator
Privacy Officer
Healthcare Administrator
Compliance Manager
Legal Counsel

Find the exact document you need

No matches found.

Military Medical Record Request Form

U.S. legal document for requesting military medical records in compliance with federal privacy laws.

How Cambridge United Uses Genie AI to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Authorization For Disclosure Of Medical Information?

What sections should be included in a Authorization For Disclosure Of Medical Information?

What sections are optional to include in a Authorization For Disclosure Of Medical Information?

What schedules should be included in a Authorization For Disclosure Of Medical Information?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Military Medical Record Request Form

Employment Background Check Release Form

Phi Consent Form

Phi Authorization Form

Dr Work Release Form

Police Vehicle Release Form

Authorization For Release Of Protected Health Information Phi

Form For Requesting Medical Records

Share Medical Information Form

Release Of Records Request Form

Release Of Information Statement

Release Form From Police Department

Printable Work Release Form

Military Dependent Medical Records Request Form

Medical Records Pick Up Form

Letter For Medical Records Request

Generic Dental Records Release Form

Employee Photo Consent Form Gdpr

Dental Release Of Information Form

CT Medical Records Release Form

Consent For Use And Disclosure Of Health Information Form

Authorization To Release Rental History

Authorization To Release Credit Information Form

Authorization To Disclose Medical Information Form

Authorization Release Form For Background Check

Athletic Medical Release Form

Minor Medical Treatment Authorization Form

Medical Consent Form For Temporary Guardian

Authorization For Release

Written Authorization To Release Information

Workers Comp Medical Release Form

Work Release Form Hospital

Veterinary Medical Release Form

Universal Medical Release Form

Service Release Form

Revocation Of Release Of Information Form

Release Form For Video Recording

Records Request Form Medical

Public Adjuster Release Form

Physician Medical Release Form

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Templates

Contract Templates

Letter Templates

Policy Templates

Industries

Legal Services

Manufacturing

Construction

Solutions

Use Cases

Company Types

Comparisons

Business Categories

Teams

Information

Generate Legal Docs Free