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Simple release of information form

General release of information form pdf 2025

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The document is an authorization form from Denton Heart Group allowing the release of a patient's medical records for various purposes such as continuing medical care, insurance, legal matters, and personal use. It specifies the types of information to be released, including history and physical reports, lab results, and consultation reports. The patient must provide their personal information and designate the recipient of the records. The form emphasizes confidentiality and the patient's right to revoke the authorization.

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Click ‘Get Form’ to open the general release of information form in our platform's editor.
Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
Fill in the date(s) of service and social security number to provide complete patient identification.
Select the purpose for which patient information is needed by checking the appropriate boxes, such as Continuing Medical Care or Insurance.
In the 'Information to be Released' section, check all relevant types of records you wish to access, including History & Physical or Lab/Path Reports.
Specify who will receive this information by filling out their name or title and address in the 'TO' section.
Complete the 'FROM' section with your own details, ensuring accurate contact information is provided.
Read through the confidentiality statement carefully before signing and dating at the bottom of the form.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is an information release form?

A Release of Information (ROI) form is a legal document used to obtain a persons consent to disclose their personal information, typically in healthcare, legal, or business contexts.

Does a HIPAA release form have to be docHubd?

478-Does the Privacy Rule require that an authorization be docHubd or include a witness signature. The Privacy Rule does not require that a document be docHubd or witnessed.

Do you have to fill out a release of information form?

To respect HIPAA compliance rules, a signed HIPAA release form must be obtained from a patient before their protected health information can be shared with other individuals or organizations, except in the case of routine disclosures for treatment, payment or healthcare operations permitted by the HIPAA Privacy Rule.

What are the 8 requirements of a valid authorization to release information?

8 Key Elements of a Compliant Medical Records Release Form Patient Information. Purpose of Request. Dates of Service. Recipient Information. Valid Authorization Signature. Date of Signature. Restrictions or Limitations. Revocation Clause.

How do I create a release form?

Key form fields typically include: Names and contact details of the individual giving consent. Description of the media being released. Intended use of the media. Specific terms and conditions or limitations. Duration of the consent. Signature.