Release Of Information Request Form for the United States

Release Of Information Request Form Template for United States

A Release of Information Request Form is a legally binding document used in the United States to authorize the disclosure of protected health information (PHI) from one party to another. This document complies with HIPAA regulations and state-specific privacy laws, providing a standardized method for requesting and authorizing the transfer of medical records, test results, treatment information, and other protected health data. The form includes specific provisions for patient identification, scope of information to be released, duration of authorization, and intended use of the information.

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What is a Release Of Information Request Form?

The Release of Information Request Form serves as a critical tool in healthcare information management, ensuring compliance with federal and state privacy regulations. This document is essential when medical information needs to be shared between healthcare providers, insurance companies, legal representatives, or other authorized parties. The form must meet HIPAA requirements and often includes additional state-specific provisions. It typically specifies what information can be released, to whom, for what purpose, and for how long the authorization remains valid. Healthcare organizations use this form to protect patient privacy while facilitating necessary information exchange.

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

1. Patient Information: Basic identifying information about the patient requesting information including full name, date of birth, address, contact details, and medical record number if applicable

2. Information to be Released: Detailed specification of what medical information is to be released, including date ranges, types of records, and any specific exclusions

3. Purpose of Release: Statement of the specific reason for requesting the information release (e.g., continuing care, legal purposes, insurance, personal records)

4. Authorization Period: Specification of the timeframe for which the authorization is valid, including start and end dates

5. Recipient Information: Complete details of the person or entity who will receive the information, including name, organization, address, and contact information

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

1. Specific Authorization for Sensitive Information: Additional authorization section for release of specially protected information such as mental health records, substance abuse treatment, HIV/AIDS information, or genetic testing results

2. Electronic Delivery Authorization: Special authorization section for electronic transmission of records, including email addresses and acknowledgment of electronic transmission risks

3. Research Authorization: Additional section for authorizing use of information in research, including scope of research use and time limitations

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

1. Fee Schedule: Comprehensive list of applicable fees for record copying, processing, and transmission methods

2. State-Specific Notices: Required state law disclosures and notices regarding patient rights and information privacy

3. Identity Verification Requirements: Detailed list of acceptable forms of identification and verification procedures for release of information

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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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Medical Records
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Medical Records Administrator
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Military Medical Record Request Form

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

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What is a Release Of Information Request Form?

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

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

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

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