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Permission To Release Information Form for the United States

Permission To Release Information Form Template for United States

A Permission to Release Information Form is a legal document used in the United States that authorizes the disclosure of specific personal information from one party to another. The document complies with federal privacy laws including HIPAA, FERPA, and GLBA, as well as state-specific privacy regulations. It details the scope of information to be released, the purpose of disclosure, duration of authorization, and includes provisions for revocation.

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What is a Permission To Release Information Form?

The Permission To Release Information Form serves as a crucial legal instrument in the United States for managing the authorized disclosure of personal information. This document is essential when organizations need to share protected information while maintaining compliance with federal and state privacy laws. It's commonly used in healthcare settings for medical records, educational institutions for student records, and financial institutions for sharing sensitive financial information. The form typically includes specific details about what information can be shared, with whom, for how long, and under what circumstances, while ensuring the information owner's rights are protected.

What sections should be included in a Permission To Release Information Form?

1. Identification of Parties: Details of the individual granting permission and the organization/entity receiving authorization

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

3. Information to be Released: Specific description of what information is authorized for release

4. Duration: Time period for which the authorization is valid

5. Revocation Rights: Statement of right to revoke authorization and process for doing so

6. Authorization Statement: Formal statement of consent

7. Signature Block: Space for signature, date, and witness if required

What sections are optional to include in a Permission To Release Information Form?

1. Redisclosure Notice: Statement about potential redisclosure of information, used when HIPAA applies

2. Special Categories: Specific authorization for sensitive information (HIV, mental health, etc.), used when applicable

3. Payment Notice: If fees apply for releasing information

4. State-Specific Disclosures: Additional disclosures required by specific states

What schedules should be included in a Permission To Release Information Form?

1. Description of Records: Detailed list of specific records to be released

2. Authorization Recipients: List of specific individuals/entities authorized to receive information

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

Jurisdiction

United States

Publisher

Genie AI

Cost

Free to use
Clauses


















Industries

HIPAA: Health Insurance Portability and Accountability Act - Critical for protecting medical information and health records. Must be considered if the form involves any health-related data.

FERPA: Family Educational Rights and Privacy Act - Essential when dealing with educational records and student information. Sets standards for the protection of student privacy.

GLBA: Gramm-Leach-Bliley Act - Governs the handling of financial information and requires financial institutions to explain their information-sharing practices to customers.

CCPA: California Consumer Privacy Act - Must be considered if California residents are involved. Provides California residents with specific rights regarding their personal information.

FTC Regulations: Federal Trade Commission regulations covering privacy practices, data protection requirements, and consumer protection standards that must be incorporated into information release forms.

Bank Secrecy Act: Relevant for financial sector information releases. Requires financial institutions to assist government agencies in detecting and preventing money laundering.

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Expands HIPAA requirements and strengthens standards for electronic health information security.

FCRA: Fair Credit Reporting Act - Must be considered when dealing with credit reporting information and consumer reports.

Legal Age Requirements: State-specific requirements regarding legal age of consent for releasing information and authority to sign legal documents.

Authorization Requirements: Legal requirements for valid authorization including clear identification of parties, specific information to be released, purpose, duration, and right to revoke.

ADA Compliance: Americans with Disabilities Act requirements ensuring the form is accessible and understandable to all individuals, including those with disabilities.

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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