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Lovelace UNM Rehabilitation Hospital 505 Elm Street NE Albuquerque, NM 87102RELEASE OF INFORMATION AUTHORIZATION/REQUEST ROID0019 (Rev 08/04/20)We are not able to process incomplete authorizations.

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How to fill out release of information authorization

01

Obtain the release of information authorization form from the appropriate organization or healthcare provider.

02

Fill out your personal information including your full name, date of birth, address, and contact information.

03

Specify the information you are authorizing to be released by checking the relevant boxes or writing in the specific details.

04

Sign and date the form to acknowledge your consent.

05

If necessary, have a witness or notary present to sign and validate the form.

Who needs release of information authorization?

01

Individuals who wish to authorize the release of their personal information to a designated party or organization.

02

Healthcare providers who need to obtain consent from patients in order to share medical records with other healthcare professionals.

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What is release of information authorization?

Release of information authorization is a legal document that allows an individual to grant permission for an organization, such as a healthcare provider or employer, to disclose personal information to a third party.

Who is required to file release of information authorization?

Individuals who wish to have their personal information shared with another party are required to file a release of information authorization.

How to fill out release of information authorization?

To fill out a release of information authorization, you typically need to provide details such as your full name, the name of the entity releasing information, the name of the entity receiving information, the specific information to be disclosed, and your signature.

What is the purpose of release of information authorization?

The purpose of release of information authorization is to ensure that individuals have control over their personal information and can dictate who has access to it and for what purposes.

What information must be reported on release of information authorization?

The information that must be reported typically includes the individual's name, the types of information to be disclosed, the names of the parties involved, the duration of the authorization, and the individual's signature.

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