Release Of Information Statement for the United States

Release Of Information Statement Template for United States

A Release of Information Statement is a legal document used in the United States that authorizes the disclosure of specific confidential information from one party to another. The document complies with federal regulations including HIPAA, FERPA, and various state privacy laws, providing legal protection for both the information holder and recipient. It details the scope of information to be shared, the purpose of disclosure, and the duration of the authorization.

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What is a Release Of Information Statement?

A Release of Information Statement serves as a critical tool in managing the disclosure of confidential information while maintaining compliance with U.S. privacy laws. This document is essential when any protected information needs to be shared between parties, whether in healthcare, education, or other regulated sectors. The statement typically specifies what information can be released, to whom, for what purpose, and for how long. It includes necessary provisions to comply with relevant federal and state privacy laws, and often requires specific language mandated by regulations such as HIPAA.

What sections should be included in a Release Of Information Statement?

1. Identification Information: Details of the person/entity authorizing information release, including full name, address, date of birth, and any relevant identification numbers

2. Information to be Released: Specific and detailed description of what information is authorized for release, including the nature, scope, and dates of information

3. Purpose of Release: Clear statement of the purpose(s) for which the released information will be used

4. Recipient Information: Complete details of the person(s) or organization(s) authorized to receive the information

5. Duration: Specific time period for which the authorization is valid, including start and end dates

6. Signature Block: Space for authorization signature, date, and witness signatures if required

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

1. Revocation Rights: Statement explaining the right to revoke the authorization and the process for doing so

2. Re-disclosure Notice: Statement about potential re-disclosure of information and any limitations on further sharing

3. Special Categories Authorization: Specific authorization sections for sensitive information such as mental health, HIV, or substance abuse records

What schedules should be included in a Release Of Information Statement?

1. Schedule A - Identity Verification Documents: List of acceptable identification documents and copies of provided identification

2. Schedule B - Specific Records List: Detailed inventory of specific records authorized for release

3. Schedule C - Additional Authorization Forms: Any supplementary forms required by specific institutions or 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

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Healthcare
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Privacy Officer
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Industries

HIPAA: Health Insurance Portability and Accountability Act - Federal law governing the protection and privacy of medical information and health records

FERPA: Family Educational Rights and Privacy Act - Federal law that protects the privacy of student education records

GLBA: Gramm-Leach-Bliley Act - Federal law requiring financial institutions to explain their information-sharing practices and protect sensitive data

Privacy Act of 1974: Federal law establishing a code of fair information practices governing the collection, maintenance, use, and dissemination of personal information maintained by federal agencies

FCRA: Fair Credit Reporting Act - Federal law regulating the collection, dissemination, and use of consumer credit information

CCPA: California Consumer Privacy Act - State law providing California residents with rights regarding their personal information and imposing obligations on businesses collecting it

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Expands HIPAA requirements and strengthens privacy and security protections for health information

SEC Regulations: Securities and Exchange Commission regulations governing the disclosure and protection of financial information in the securities industry

Bank Secrecy Act: Federal law requiring financial institutions to assist government agencies in detecting and preventing money laundering, including requirements for information sharing

Telecommunications Act: Federal law governing telecommunications services, including requirements for protecting customer proprietary network information (CPNI)

Contract Law Requirements: General principles of contract law including offer, acceptance, consideration, and capacity that affect the validity of information release agreements

Consent Requirements: Legal principles governing what constitutes valid consent for releasing information, including requirements for informed and voluntary consent

Right to Revoke: Legal principle establishing that individuals generally have the right to revoke their authorization for information sharing at any time

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What is a Release Of Information Statement?

What sections should be included in a Release Of Information Statement?

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

What schedules should be included in a Release Of Information Statement?

Authors

Alex Denne

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