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Specifies the authorized recipients, the description of information and dates of service, and the purposes for disclosure, such as patient request or insurance claims. States that re-disclosure may remove federal privacy protection, sets a default validity of 1 year, includes categories of allowable records, and explains patient rights to inspect, copy, and revoke with stated exceptions.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-release-of-information/283970/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-release-of-information/283970.png","ImageObject",442,249,{"name":88,"@type":89},"supergirl","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How long is this authorization valid?","Question",{"text":109,"@type":110},"This authorization is valid for 1 year unless otherwise specified.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Who can receive the patient’s information under this form?",{"text":114,"@type":110},"The form lists “Name and Address of Persons/Organizations authorized to receive information” and allows selection of record types the recipient may receive.",{"name":116,"@type":107,"acceptedAnswer":117},"Can the patient revoke this authorization?",{"text":118,"@type":110},"Yes. The patient may revoke at any time by notifying SVHC in writing, except to the extent action has already been taken in reliance on the authorization or other conditions apply.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283970,1790201080,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Southwestern Vermont Medical Center  \n# Authorization for Release of Information\n\nMR\\#:                      \n                             Date of Birth:             \nPatient Name:  \nPlease Print  \nAddress:                                                                                                                                            \nPiease Print  \nI hereby authorize SVHC the use or disclosure of my protected health information as described below.I understandthat thé information l authorize a person or entity to receive may be re-disclosed and no longer protected by federalprivacy regulations.This authorization is valid for 1 year unless otherwise specified.  \nName and Address of Persons/Organizations authorized to receive information:  \nSpecific description of information that may be used/disclosed and dates of service:  \n□X-ray Films and Report□History and PhysicalOffice Notes□operative Note  \n□ER Report□Outpatient Department  \n□Discharge SummaryOther                                  Describe  \nThis authorization permits SVHC to disclose my protected health information from my health record with no limitationsplaced on history of ilness diagnostic or therapeutic information including any treatment for alcohol and drug abuse,psychiatric impairment,HIVIAIDS related illnesses or genetic testing.  \nThe information will be used /disclosed for the following purpose(s):  \n□Requested by the patient and for the patient(not necessary to disclose purpose).  \n□ Insurance Claim  \n Other:(Describe)                                               \nI understand that this authorization is voluntary and that I may refuse to sign this authorization.I do not need tosign this form to ensure healthcare treatment.  \n□I understand that I may inspect or copy the information used or disclosed.  \n!understand that I may revoke this authorization at any time by notifying SVHC,in writing,except to the extentthat:  \n1.Action has been taken in reliance on this authorization;or  \n2.If this authorization is obtained as a condition of obtaining coverage,other law provides the insurer with theright to contest a claim under the policy or the policy itself.  \nSignature of Patient or Patient RepresentativeDateRelationship to patient,or representative's authority to act for the patient(if applicable)  \nRequest Received:                Date Processed:       Copy of Authorization given to theindividual  \nInitial of person finalizing request:  \nsjb Form\\#S5349  \nauthorization_for_release_of_information_6142005  \ncreated:6142005 revised:5242007","cbCaihUZzH6w1fb5","https://ap.wps.com/l/cbCaihUZzH6w1fb5","pdf",60479,"English","# Authorization for Release of Information\n## Patient information and identification\n## Recipients and permitted records\n## Purpose of disclosure\n## Patient rights, validity, and revocation","[{\"question\":\"How long is this authorization valid?\",\"answer\":\"This authorization is valid for 1 year unless otherwise specified.\"},{\"question\":\"Who can receive the patient’s information under this form?\",\"answer\":\"The form lists “Name and Address of Persons/Organizations authorized to receive information” and allows selection of record types the recipient may receive.\"},{\"question\":\"Can the patient revoke this authorization?\",\"answer\":\"Yes. The patient may revoke at any time by notifying SVHC in writing, except to the extent action has already been taken in reliance on the authorization or other conditions apply.\"}]","Authorization for Release of Information | PDF",1789623606]