Basic Release Of Information Form for the United States

Basic Release Of Information Form Template for United States

A Basic Release of Information Form is a legal document used in the United States that authorizes the disclosure of specific personal information from one party to another. This document complies with federal regulations including HIPAA and FERPA, as well as state-specific privacy laws. It serves as a formal consent mechanism, detailing what information can be shared, with whom, for what purpose, and for how long. The form includes necessary safeguards and disclosures required by U.S. federal and state privacy laws.

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What is a Basic Release Of Information Form?

The Basic Release of Information Form is essential in situations where protected personal information needs to be shared between authorized parties. This document is commonly used across various sectors in the United States, particularly in healthcare, education, and financial services. It must comply with federal regulations such as HIPAA and FERPA, as well as state-specific privacy laws. The form typically includes detailed information about what is being shared, who can access it, the duration of the authorization, and the rights of the information owner. It serves as both a protection mechanism for sensitive information and a formal record of consent.

What sections should be included in a Basic Release Of Information Form?

1. Individual Information: Basic information about the person whose information is being released including name, date of birth, address, and contact details

2. Authorization Statement: Clear statement of authorization to release information, including acknowledgment of understanding

3. Information to be Released: Specific description of what information can be released, including date ranges and types of records

4. Purpose of Release: Stated purpose for releasing the information, whether for medical care, legal purposes, or personal records

5. Duration: How long the authorization remains valid, including specific start and end dates

6. Recipient Information: Who is authorized to receive the information, including name, organization, address, and contact details

7. Signature Block: Space for signature, date, and witness signature if required

What sections are optional to include in a Basic Release Of Information Form?

1. Revocation Rights: Information about right to revoke authorization and process for doing so under HIPAA requirements

2. Special Categories: Specific checkboxes for sensitive information such as mental health records, HIV status, or substance abuse treatment records

3. Electronic Delivery Authorization: Permission for electronic transmission of information and acknowledgment of associated risks

What schedules should be included in a Basic Release Of Information Form?

1. Information Detail Sheet: Detailed list of specific records to be released, including dates, types, and any specific exclusions

2. State-Specific Addendum: Additional requirements and disclosures based on applicable state law requirements

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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

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What is a Basic Release Of Information Form?

What sections should be included in a Basic Release Of Information Form?

What sections are optional to include in a Basic Release Of Information Form?

What schedules should be included in a Basic Release Of Information Form?

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