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3100 Plaza Properties Blvd., Columbus, OH 4319 Phone: 614.383.6200 or 614.383.6202 Fax: 614.383.6087 Patients Name Address Phone Date of Birth AUTHORIZATION TO RELEASE INFORMATION I, authorize and

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What is authorization to release information?

Authorization to release information is a legal document that allows one party to disclose personal information about an individual to another party.

Who is required to file authorization to release information?

Any individual or organization that needs to share personal information about someone else must file authorization to release information.

How to fill out authorization to release information?

To fill out an authorization to release information, one must provide details about the individual whose information is being released, specify the information to be disclosed, state the purpose of the disclosure, and sign and date the form.

What is the purpose of authorization to release information?

The purpose of authorization to release information is to protect the privacy of individuals by ensuring that their personal information is only shared with their explicit consent.

What information must be reported on authorization to release information?

The information reported on authorization to release information typically includes the name and contact information of the parties involved, the specific information to be disclosed, the purpose of the disclosure, and any limitations on the disclosure.

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