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AUTHORIZATION TO RELEASE INFORMATION FROM A HEALTH RECORD Please print clearly Name of Patient: Date of Birth of Patient: Family Doctor (if applicable): Address of Patient: OSM I.D.# Authorization

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What is authorization to release info?

Authorization to release info is a document that allows a third party to access and release certain information about an individual.

Who is required to file authorization to release info?

The individual who wants their information released or a legal guardian may be required to file an authorization to release info.

How to fill out authorization to release info?

To fill out an authorization to release info, the individual must provide their personal information, specify the information to be released, and sign the document.

What is the purpose of authorization to release info?

The purpose of authorization to release info is to protect an individual's privacy and ensure that their information is only shared with authorized parties.

What information must be reported on authorization to release info?

The authorization to release info must include the individual's name, date of birth, the information to be released, the purpose of the release, and any limitations on the release of information.

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