The Legal Release Of Information Form serves as a critical tool for managing the authorized disclosure of sensitive information in compliance with U.S. privacy laws. This document becomes necessary when any individual or organization needs to share protected information with a third party, whether for medical, educational, financial, or legal purposes. The form typically includes specific details about what information can be shared, with whom, for how long, and under what circumstances. It must comply with various federal regulations such as HIPAA, FERPA, or GLBA, depending on the nature of the information, as well as applicable state privacy laws.
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1. Information Provider Details: Full name and contact information of the person/entity releasing information
2. Information Recipient Details: Full name and contact information of the person/entity receiving information
3. Information to be Released: Specific description of information being authorized for release
4. Purpose of Release: Clear statement of why the information is being released
5. Duration: Time period for which the release is valid
6. Signature Block: Space for dated signatures of all relevant parties
1. Revocation Rights: Statement about right to revoke authorization, used when required by specific regulations
2. Re-disclosure Notice: Warning about potential re-disclosure, required for HIPAA-covered information
3. Special Categories: Additional authorizations for sensitive information (HIV, mental health, etc.)
1. Detailed Information List: Itemized list of specific records/information to be released
2. Statutory Notices: Required notices based on jurisdiction or type of information
3. Authorization Verification Form: Form to verify identity/authority of person giving authorization
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