Fillable Printable Sample Authorization to Release Information Form

Sample Authorization to Release Information Form

SAMPLE AUTHORIZATION TO RELEASE INFORMATION FORM

[Name and Address of Your Organization]

Authorization to Release Information

Consumer’s Name: Date of Birth:

Consumer’s Social Security Number:

I hereby authorize [Name of Your Organization] to (check one): _____ obtain from the following

_____ release to the following

Name:

Address:

the following documents/information from the records pertaining to services received

Date of Service:

The documents to be released are described or listed as:

The records are required for the specific purpose of:

I understand that my authorization will remain effective from the date of my signature until

, and that the information will be handled confidentially in compliance with

all applicable federal laws.

I understand that I may see the information that is to be sent, and that I may revoke the authorization

at any time by written, dated communication.

I have read and understand the nature of this release.

___________________________________________________ ____________________

Signature of Consumer/Consumer’s Designated Representative Date

___________________________________________________ ____________________

Witness Date