Confidential Information Releases

for Your State

For use when authorizing another to release confidential information on your behalf. This form contains an expiration date and can be used to authorize a physician, attorney, hospital, clinic or school to release confidential information about you.

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This Authorization to Release Confidential Information will ensure that only the information you specify is released on your behalf. This authorization can be given to a physician, attorney, hospital, clinic or school to release confidential information on your behalf. The types of confidential information to be released can vary from financial, educational and legal to your social interactions, both online and in person. This Authorization to Release Confidential Information is beneficial because it protects not only your privacy but contains an expiration date and can be revoked at any time.

These important provisions are included in this Authorization to Release Confidential Information:
  • Authorization Information: Indicates the name and address of the individual authorizing release of the information and the individual or entity who will release the confidential information;
  • Types of Confidential Information: Sets forth a checklist covering most types of confidential information;
  • Purpose of Use: Outlines the purposes the confidential information may be used for;
  • Revocation and Expiration Dates: This Authorization may be revoked at any time or on a specified expiration date.

Protect yourself and your Rights by using our professionally prepared up-to-date forms.

This attorney prepared packet includes:
  1. General Information
  2. Instructions and Checklist
  3. Authorization to Release Confidential Information
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.













Authorization to Release
Confidential Information








This Packet Includes:
1.  General Information
2.  Instructions and Checklist
3.  Authorization to Release Confidential Information





General Information
Authorization to Release Confidential Information

One of the most pressing issues in todays high-tech world is privacy.  Although privacy protection is a concern for both businesses and individuals, it is not uncommon to find yourself in a situation where private information must be disclosed.  For example, a prospective employer or landlord may require personal, financial or even medical information.  In these circumstances it is important that you use a document which allows a limited release of information, thereby maintaining as much protection as possible.  Our Authorization to Release Confidential Information is designed for this situation.  

Our Authorization to Release Confidential Information form will ensure that only the information you specify is released on your behalf.  This form can be given to your physicians and attorneys, any hospitals and clinics and schools you have attended in order to release personal information on your behalf.  The information to be released varies and can range from financial, educational and legal information to your social interactions both online and in person.  This form is also beneficial because it contains an expiration date and a clause stating the form can be revoked at any time.  

This Authorization to Release Confidential Information protects your privacy and can be used once or numerous times.  By purchasing our up-to-date form prepared by an attorney, you save both your money and peace of mind.  This form can also be used in all states and is available for immediate download.  





Instructions and Checklist
Authorization to Release Confidential Information

  Read the authorization carefully.

   Insert all requested information in the spaces provided on the form.

     This form contains sensitive and confidential information.  Please release only information for its intended purposes.  

   This form contains an expiration date provision.  Please review this provision carefully before inserting the expiration date, as it will nullify the release.

     This form contains the basic terms and language that should be included in similar authorizations.  

   Both parties should retain either an original or copy of the signed agreement.

   All legal documents should be kept in a safe location such as a fireproof safe or safe deposit box.  







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AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

I, _________________________ residing at _______________________________________ authorize the following person:

_______________________________ (Individual, Physician, Hospital, Clinic, Attorney, School etc.) _________________________________________________________________________

To release the following specific confidential information:

(Check all that are applicable)
[  ] Educational Information consisting of ____________________________________
[  ] Developmental Information consisting of _________________________________
[  ] Financial Information consisting of ____________________________________
[  ] Legal Information consisting of ________________________________________
[  ] Medical Information consisting of ______________________________________
[  ] HIV related Information consisting of ___________________________________
[  ] Psychological Reports consisting of _____________________________________
[  ] Social History consisting of ____________________________________________
[  ] Other Information consisting of _______________________________________

To the following individual or organization _________________________________________ of ___________________________________________________________________________

The information released may be used by the individual or the organization for the following purpose: ______________________________________________________________________

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing.  I understand that the revocation will not apply to information that has already been released in response to this authorization.

EXPIRATION DATE:  This authorization will expire on _____________________

This form was read by me or was read to me and I understand its meaning.  All the applicable blanks were filled in before the form was signed by me.


                     ____________________________________
                     Signature




Number of Pages6
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#34855

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