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Authorization for release of information template

AUTHORIZATION TO RELEASE MEDICAL RECORD INFORMATION 2025

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The document is an authorization form allowing the Ohio Surgery Center to release specific medical records of a patient to a designated recipient for a stated purpose. It outlines the types of records that can be released, the duration of the authorization, and conditions regarding revocation and liability. The patient or responsible party must sign the document to grant permission.

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Click ‘Get Form’ to open the AUTHORIZATION TO RELEASE MEDICAL RECORD INFORMATION in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping purposes.
Print the patient's name clearly in the designated field to ensure accurate identification.
In the 'To' section, input the name of the institution holding the records, which in this case is Ohio Surgery Center.
Fill in the address details of Ohio Surgery Center, including street address, city, state, and zip code.
Next, specify who will receive the records by filling out their address information in the 'I AUTHORIZE YOU TO RELEASE RECORDS TO' section.
Indicate the purpose for releasing information in the 'FOR THE PURPOSE OF' field. Be specific to avoid any confusion.
Select which portions of medical records you wish to release by checking appropriate boxes such as Discharge Summary or Lab Report.
Sign and date at the bottom of the form as either patient or responsible party. Ensure a witness also signs if required.

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What does release authorization mean?

A medical release form (also known as a medical records release form or authority to release medical information) is a legal document patients can sign to permit healthcare providers to share their private health information with specified third parties.

What is medical records release authorization?

A medical records release is a written authorization for health providers to release information to the patient as well as someone other than the patient.

How to fill out an authorization for release of medical information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What information should be on the authorization to release information?

All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.

What is authorization for release of medical records?

An authorization for release of medical information form is a signed document that gives a healthcare provider permission to release a patients medical records. This consent is required by law in many countries to protect the patients sensitive data.

authorization to release information form

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How do you write an authorization letter for medical records release?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.