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1. Patient Information: Full name, date of birth, address, contact information, and medical record number of the patient
2. Healthcare Provider Information: Name and address of the healthcare facility/provider who will be releasing the information
3. Recipient Information: Name and address of person/entity authorized to receive the medical information
4. Information to be Released: Specific description of medical information to be disclosed, including dates of service if applicable
5. Purpose of Disclosure: Clear statement explaining why the medical information is being released
6. Duration of Authorization: Expiration date or event for the authorization, as required by HIPAA
7. Rights and Declarations: Statement of patient rights including right to revoke authorization and statement that treatment isn't conditioned on signing
1. Specific Restrictions: Optional section for specifying any limitations on the information to be shared
2. Electronic Delivery Authorization: Additional authorization specific to electronic transmission of records
3. Substance Abuse Records: Special authorization section required when releasing substance abuse treatment records under 42 CFR Part 2
1. Identity Verification Documents: Attached copies of government-issued ID or other required verification documents
2. Legal Authority Documentation: Attached documentation of legal authority (power of attorney, guardianship papers) when someone other than patient is authorizing
3. State-Specific Forms: Any additional state-required forms or documentation for medical record release
Medical Abstract
Authorization Period
Healthcare Provider
Covered Entity
Designated Recipient
Medical Records
Personal Representative
Treatment Information
Health Information
Disclosure
Re-disclosure
Revocation
Electronic Health Record (EHR)
Minimum Necessary Information
Authorized Use
Confidential Communications
Privacy Rule
Authorization Expiration Date
Legal Representative
Information Description
Purpose of Disclosure
Duration and Expiration
Revocation Rights
Re-disclosure Notice
Privacy Rights
Medical Records Access
Confidentiality
Information Security
Electronic Transmission
Legal Representatives
Consent Verification
Distribution Limitations
Patient Rights
Release Authorization
Data Protection
Identity Verification
Record Delivery Method
Termination Rights
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Genie’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; Genie’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it


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