51ÊÓÆµÔÚÏß

Standard Release Of Information Form for the United States

Standard Release Of Information Form Template for United States

A Standard Release of Information Form is a legal document used in the United States that authorizes the disclosure of an individual's protected information from one party to another. The document must comply with federal regulations including HIPAA and state-specific privacy laws. It includes detailed specifications about what information can be shared, with whom, for what purpose, and for how long. The form serves as a formal record of consent and protects both the information provider and recipient.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

Download a Standard Template

4.6 / 5
4.8 / 5
Access for free
OR

Alternatively: Run an advanced review of an existing
Standard Release Of Information Form

Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

What is a Standard Release Of Information Form?

The Standard Release of Information Form is a crucial document used when there's a need to share protected personal information between authorized parties. This form, governed by U.S. federal and state regulations, ensures compliance with HIPAA and other privacy laws while protecting the rights of the information owner. It's commonly used in healthcare settings but extends to educational institutions, insurance companies, and legal services. The form typically includes specific details about the information being released, the purpose of the release, time limitations, and the rights of the individual providing consent. It serves as both a legal authorization and a record-keeping tool for tracking information disclosure.

What sections should be included in a Standard Release Of Information Form?

1. Patient Information: Full legal name, date of birth, contact information, and other identifying details of the patient

2. Information Provider: Details of the healthcare provider/entity releasing the information including name, address, and contact information

3. Information Recipient: Details of the person/entity authorized to receive the information including name, address, and contact information

4. Information to be Released: Specific description of what information is authorized for release, including date ranges and types of records

5. Purpose of Release: Stated reason for information disclosure (e.g., continuing care, legal purposes, insurance)

6. Duration: Expiration date or event for the authorization, as required by HIPAA

7. Rights Statement: Statement of patient rights including right to revoke authorization and right to refuse to sign

8. Signatures: Patient or authorized representative signature block with date and relationship to patient if applicable

What sections are optional to include in a Standard Release Of Information Form?

1. Specific Authorization: Additional authorization section for sensitive information such as HIV status, mental health records, or substance abuse treatment

2. Witness Section: Space for witness signature when required by state law or organizational policy

3. Payment Information: Details about any fees associated with records release and payment methods accepted

What schedules should be included in a Standard Release Of Information Form?

1. State-Specific Addendum: Additional provisions and requirements specific to the state where the release is being executed

2. Records Checklist: Detailed itemized checklist of specific records being requested or released

3. Fee Schedule: Comprehensive breakdown of applicable fees for record copying and release services

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

Document Type

Authorization Form

Cost

Free to use
Clauses





















Industries

HIPAA: Health Insurance Portability and Accountability Act of 1996 - Includes Privacy Rule requirements, Security Rule requirements, and provisions for Patient rights regarding Protected Health Information (PHI)

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Provides enhanced privacy and security protections and breach notification requirements

State Privacy Laws: State-specific privacy requirements, including specific language requirements for release forms and state-specific retention requirements

FERPA: Family Educational Rights and Privacy Act - Relevant for educational records and student health records

42 CFR Part 2: Special privacy protections specifically applicable to substance use disorder treatment records

ADA: Americans with Disabilities Act - Covers accessibility requirements for forms and non-discrimination provisions

State Medical Record Laws: State-specific requirements for medical record access and timing requirements for record release

Form Essential Elements: Key components including: identification of parties, description of information to be released, purpose of disclosure, expiration date, right to revoke, re-disclosure statement, patient rights statement, signature requirements, and witness/notary requirements

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

Find the exact document you need

Vital Records Authorisation Form

A U.S. legal form authorizing the release of vital records while ensuring compliance with federal and state privacy regulations.

find out more

Tenant Authorisation Form

A U.S.-compliant legal form authorizing property managers to conduct necessary background and credit checks on prospective tenants.

find out more

Parental Authorisation Form

A U.S.-compliant legal document allowing parents/guardians to authorize third parties to make specific decisions or take actions regarding their minor child.

find out more

Overtime Authorisation Form

A U.S.-compliant form for requesting and authorizing employee overtime work hours under FLSA requirements.

find out more

Return Merchandise Authorisation Form

A U.S.-compliant document that authorizes and tracks the return of merchandise from customers to merchants, ensuring proper documentation and processing of product returns.

find out more

Non Borrower Credit Authorisation Form

A US-compliant authorization form allowing financial institutions to check a non-borrower's credit information as part of a loan application process.

find out more

Manufacturer Authorisation Form

A U.S.-governed legal document that authorizes a party to officially represent, sell, or service a manufacturer's products within specified parameters.

find out more

Disbursement Authorisation Form

A U.S.-compliant financial control document used to authorize and document the release of funds, requiring appropriate approvals and supporting documentation.

find out more

Appointment Of Authorised Representative Form

A U.S. legal document that formally authorizes a representative to act on behalf of a principal in specified matters, complying with state-specific requirements for representation and agency relationships.

find out more

Pet Care Emergency Authorisation Form

A US-compliant legal form authorizing designated individuals to make emergency medical decisions for pets when owners are unavailable.

find out more

Vendor Direct Deposit Authorisation Form

A U.S.-compliant authorization form enabling electronic payments from organizations to vendors through direct deposit, incorporating necessary banking details and security measures.

find out more

Deposit Authorisation Form

A U.S.-compliant banking form that authorizes financial institutions to process deposits into specified accounts, establishing the legal framework for deposit transactions.

find out more

Medical Authorisation Form For Adults

A U.S.-compliant form authorizing the release of medical information and healthcare decision-making rights for adult patients, adhering to HIPAA and state regulations.

find out more

Authorisation Of Release Of Unemployment Records Form

A U.S.-compliant form authorizing the release of individual unemployment records to designated recipients, meeting federal and state privacy requirements.

find out more

Electronic Funds Transfer Authorisation Form

A U.S.-compliant authorization form for electronic funds transfers that enables secure and regulated electronic debits or credits from designated bank accounts.

find out more

Return Authorisation Form

A US-compliant document that authorizes and tracks product returns from customers to businesses, ensuring proper documentation and processing of return requests.

find out more

Payroll Authorisation Form

A U.S.-compliant authorization form enabling employers to process employee payroll payments and deductions through specified payment methods.

find out more

Check Authorisation Form

A U.S.-compliant form authorizing check payments from a specified bank account, used for both one-time and recurring transactions.

find out more

Authorisation For Release Of Records

A U.S.-compliant legal document authorizing the release and transfer of specific records or information from one party to another, subject to federal and state privacy laws.

find out more

Medical Records Release Authorisation Form

A HIPAA-compliant authorization form used in the U.S. healthcare system to permit the release of patient medical records to designated recipients.

find out more

Owner Authorisation Form

A U.S. legal document that grants specific permissions from a property owner to another party to act on their behalf, subject to state and federal property laws.

find out more

Payoff Authorisation Form

A U.S. legal document authorizing lenders to release loan payoff information to designated parties, commonly used in refinancing and property sales.

find out more

Agent Authorisation Form

A U.S. legal document that authorizes an agent to act on behalf of a principal, defining the scope and terms of the agency relationship.

find out more

Pre Employment Background Check Authorisation Form

A U.S.-compliant authorization form for conducting pre-employment background checks, meeting FCRA and state law requirements.

find out more

Pre Authorised Debit Form

A US-compliant legal document authorizing recurring automatic payments from a specified bank account to a service provider or merchant.

find out more

Payroll Deduction Authorisation Form

A U.S.-compliant form authorizing employers to make specific deductions from employee paychecks, adhering to federal and state wage laws.

find out more

Third Party Authorisation Form

A U.S.-governed legal document that authorizes a third party to act on behalf of an individual or organization, subject to federal and state requirements.

find out more

Authorised Representative Form

A U.S.-compliant legal form designating an individual or entity to act as an authorized representative with specified powers and authorities.

find out more

Background Check Authorisation Form

A U.S.-compliant authorization form required under FCRA for conducting employment-related background checks, obtaining candidate consent and providing required disclosures.

find out more

Direct Deposit Authorisation Form

A U.S.-compliant form authorizing automatic electronic deposits into a specified bank account for recurring payments or salary deposits.

find out more

Direct Deposit Enrolment Form

A U.S. legal document authorizing automatic electronic transfer of funds from a paying organization directly to a recipient's bank account(s).

find out more

Authorization To Release A Medical Certificate

A HIPAA-compliant U.S. legal document authorizing the release of medical certificates or records from healthcare providers to specified recipients.

find out more

Voided Check Form

A U.S.-compliant banking form used to verify account details and authorize electronic transfers, requiring a voided check attachment and account holder authorization.

find out more

Time Off Request Form

A US-compliant form for employees to request and document time off, including vacation, sick leave, and protected leave types.

find out more

Ach Form

A U.S.-compliant authorization form for electronic fund transfers through the ACH network.

find out more

Credit Reference Request Form

A U.S.-compliant form for requesting credit information about individuals or businesses, designed to meet FCRA requirements and protect all parties' interests.

find out more

Overtime Form

A U.S.-compliant form for recording and authorizing employee overtime hours, ensuring FLSA compliance and proper compensation calculation.

find out more

Representative Form Ircc

A U.S.-governed agreement establishing terms and conditions for independent contractor representation, including commission structure, territories, and compliance requirements.

find out more

Direct Debit Authorisation Form

A U.S.-compliant authorization form allowing automatic withdrawal of funds from a bank account, subject to EFTA and Regulation E requirements.

find out more

Eft Authorization Form

A US-compliant authorization form for electronic funds transfers between bank accounts, meeting EFTA and federal banking regulations.

find out more
See more related templates

³Ò±ð²Ô¾±±ð’s Security Promise

Genie is the safest place to draft. Here’s how we prioritise your privacy and security.

Your documents are private:

We do not train on your data; ³Ò±ð²Ô¾±±ð’s AI improves independently

All data stored on Genie is private to your organisation

Your documents are protected:

Your documents are protected by ultra-secure 256-bit encryption

We are ISO27001 certified, so your data is secure

Organizational security:

You retain IP ownership of your documents and their information

You have full control over your data and who gets to see it