Written Authorization To Release Information for the United States

Written Authorization To Release Information Template for United States

A Written Authorization To Release Information is a legal document used in the United States that grants permission for the disclosure of specific personal information from one party to another. It complies with federal regulations including HIPAA, FERPA, and GLBA, as well as state-specific privacy laws. The document specifies what information can be released, to whom, for what purpose, and for how long the authorization remains valid.

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What is a Written Authorization To Release Information?

A Written Authorization To Release Information serves as a crucial legal safeguard in situations where personal, confidential, or protected information needs to be shared between parties. This document is commonly used across the United States and must comply with federal regulations such as HIPAA for medical records, FERPA for educational records, and GLBA for financial information. The authorization typically includes specific details about what information can be released, who can receive it, the purpose of the release, and an expiration date. It's essential for maintaining privacy compliance while facilitating necessary information sharing.

What sections should be included in a Written Authorization To Release Information?

1. Identification of Parties: Clear identification of the authorizing individual and receiving party, including full legal names, addresses, and any relevant identification numbers

2. Information Description: Specific and detailed description of what information is authorized for release, including type, date ranges, and any specific limitations

3. Purpose Statement: Clear statement of why the information is being released and how it will be used

4. Duration: Specific expiration date or event for the authorization, including when the authorization becomes effective

5. Signature Block: Space for signatures, dates, and any required witness attestation or notarization

What sections are optional to include in a Written Authorization To Release Information?

1. Revocation Rights: Statement explaining the right to revoke authorization, process for revocation, and any limitations - include when HIPAA compliance is required

2. Redisclosure Notice: Warning about potential redisclosure of information by receiving parties - recommended when dealing with sensitive personal, medical, or financial information

3. Special Categories Consent: Specific checkboxes or statements for particularly sensitive information (HIV status, mental health records, substance abuse treatment) - include when such information may be involved

4. Cost Statement: Information about any fees or costs associated with the information release - include when applicable

What schedules should be included in a Written Authorization To Release Information?

1. Identity Verification Documents: Appendix containing copies of required identification documents or verification procedures

2. Detailed Information Schedule: Comprehensive list of specific records, documents, or information to be released when too extensive for main document

3. Required Agency Forms: Any specific forms or additional documentation required by receiving agencies or institutions

4. Privacy Notices: Required privacy notices or statements mandated by applicable laws (HIPAA, GLBA, etc.)

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

Protected Information
Authorization Period
Authorized Recipients
Confidential Information
Disclosure
Information Holder
Personal Information
Protected Health Information (PHI)
Records
Redisclosure
Release
Requesting Party
Revocation
Sensitive Information
Third Party Recipients

Clauses

Consent
Scope of Authorization
Duration and Expiration
Information Description
Purpose of Disclosure
Recipient Rights
Revocation Rights
Redisclosure Limitations
Privacy Protection
Confidentiality
Indemnification
Governing Law
Severability
Witness Requirements
Certification
Signature Authority

Relevant Industries

Healthcare
Education
Financial Services
Employment
Legal Services

Relevant Teams

Human Resources
Legal
Medical Records
Compliance
Information Management

Relevant Roles

Privacy Officer
Medical Records Administrator
HR Manager
Compliance Officer
Records Manager

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What is a Written Authorization To Release Information?

What sections should be included in a Written Authorization To Release Information?

What sections are optional to include in a Written Authorization To Release Information?

What schedules should be included in a Written Authorization To Release Information?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

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