Authorization to Release Information We are ... - Maine.gov 2025

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The General Consent for Treatment and Release of Information form is used to obtain authorization from and provide information to the patient or their representative.
What information must be included on an authorization to release information? Name of the people to whom the disclosure is being made. Name of the person authorized to disclose the information. Expiration date.
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.
The purpose of the authorization is to let former employers, educational institutions, and personal references know that the applicant about whom you are seeking information has consented to its release to you.
Authorization to release information means a written statement, signed and dated by the person empowered to authorize release of confidential information.
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Use VA Form 21-4142 to give us permission to obtain your personal information from a non-VA source like a private doctor or hospital. Examples of personal information may include your medical treatment, hospitalizations, psychotherapy, or outpatient care.

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