[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-189720-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-189720-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","health-information-disclosure-authorization-form-release-details","Health Information Disclosure Authorization Form - Release Details","","Health information disclosure authorization form template collects identifiers and contact details, including first and last name, date of birth, address, and social security number. It specifies the disclosing entity, the recipient, and the purpose and scope of the disclosure, with optional date ranges for released records. It defines how long the authorization remains effective, how revocation works, and includes required signature blocks for the individual and personal representative. It also addresses privacy protections and limits for substance use disorder records.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/health-information-disclosure-authorization-form-release-details/189720/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/health-information-disclosure-authorization-form-release-details/189720.png","ImageObject",442,249,{"name":42,"@type":43},"\tCallum ","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-02","2026-09-03",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be completed in Section I of the authorization form?","Question",{"text":63,"@type":64},"Section I collects the individual’s name, date of birth, social security number, and address details.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does Section II ask for regarding disclosure and receiving entities?",{"text":68,"@type":64},"Section II requires the disclosing entity (covered entity) information and identifies the recipient and their contact information.",{"name":70,"@type":61,"acceptedAnswer":71},"How does the form handle the authorization period, revocation, and expiration?",{"text":72,"@type":64},"The form states the authorization remains effective until revoked or until the specified expiration date or event; if none is provided, it expires in one year. It also explains that revocation must be submitted in writing to the disclosing entity.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},189720,1788398765,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":55,"slug":121},21,"Paper Templates","papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":80,"read_time":22},137451211410,"https://ap-avatar.wpscdn.com/avatar/2000bb0a9246f588df?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786362646172706240","| Section I |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name* | M. I. | Last Name * |  |  | Date of Birth * |  | Social Security Number |  |  |\n| Address |  |  |  | City |  | State |  |  | Zip Code |\n| I hereby authorize the disclosure of health information about the above individual as follows. |  |  |  |  |  |  |  |  |  |\n| Section II |  |  |  |  |  |  |  |  |  |\n| Disclosing Entity * (Covered Entity such as a health plan/insurer or provider) |  |  |  |  |  |  |  |  |  |\n| Address |  |  |  |  |  | Telephone Number |  |  |  |\n| City |  |  | State |  |  | Zip Code |  |  |  |\n| Recipient ( Person or Entity) * |  |  |  |  |  |  |  |  |  |\n| Contact Information (e.g. telephone number, email address, fax number, street address, etc.) |  |  |  |  |  |  |  |  |  |\n| Section III |  |  |  |  |  |  |  |  |  |\n| Reason for Disclosure* |  |  |  |  |  |  |  |  |  |\n| Health information to be disclosed * |  |  |  |  |  |  |  |  |  |\n| Specify time period, if desired:\u003Cbr>Release only information from the period   (mm/dd/yyyy) to   (mm/dd/yyyy) |  |  |  |  |  |  |  |  |  |\n| Section IV |  |  |  |  |  |  |  |  |  |\n| This authorization will remain in effect until revoked or shall expire on date or event specified below. I understand that I may revoke or cancel this authorization at any time by submitting written revocation in the manner specified by the disclosing entity, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will expire on the date or completion of the event stated below. If no date or event is specified below, this authorization will expire in one year. |  |  |  |  |  |  |  |  |  |\n| Expiration Date or Event   (mm/dd/yyyy) |  |  |  |  |  |  |  |  |  |\n| • I understand that I may not be denied treatment, payment, and enrollment in the health plan, or eligibility for benefits for refusing to authorize disclosure unless such denial is permitted under state and federal law.\u003Cbr>• I understand that information disclosed by this authorization, except as prohibited by 42 CFR Part 2 or other applicable law, may be subject to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule [45 CFR Part 164] . |  |  |  |  |  |  |  |  |  |\n| Signature of Individual * |  |  |  |  |  |  |  | Date* (mm/dd/yyyy) |  |\n| Signature of Personal Representative (if applicable)* (identify relationship to individual below) |  |  |  |  |  |  |  | Date* (mm/dd/yyyy) |  |\n| Relationship of Personal Representative to Individual (Personal representative shall submit proof of authority to the disclosing entity)☐ Parent ☐ Legal Guardian ☐ Healthcare Power of Attorney ☐ Executor/Administrator ☐ Other ☐ N/A |  |  |  |  |  |  |  |  |  |\n\n\n| Method of Delivery (e.g. paper, fax, electronic,) | Date Released |\n| --- | --- |\n\n\n| Section I |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name* | M. I. | Last Name * |  |  | Date of Birth * |  | Social Security Number |  |  |  |\n| Address |  |  |  |  | City |  | State |  |  | Zip Code |\n| I hereby authorize the disclosure of health information about the above individual as follows. |  |  |  |  |  |  |  |  |  |  |\n| Section II |  |  |  |  |  |  |  |  |  |  |\n| Disclosing Entity * (Name of Holder of Part 2 Program Information) |  |  |  |  |  | Telephone Number |  |  |  |  |\n| Address |  |  | City |  |  | State |  |  | Zip Code |  |\n| The information is to be provided to the following * :\u003Cbr>☐ Named Individual:\u003Cbr>☐ Named Third Party Payer:\u003Cbr>☐ Named Treatment Provider Entity:\u003Cbr>☐ Named Non-Treatment Provider (such as an intermediary or research entity)++If non-treatment provider is selected complete a, b and/or c below.\u003Cbr>a. Named Individual Participant(s):  \u003Cbr>b. Named Treatment Provider Entity Participant(s):  \u003Cbr>c. Description of Group or Class of Treatme","cbCaiv129pphoelo","https://ap.wps.com/l/cbCaiv129pphoelo","pdf",166917,"English","# Authorization Sections\n## Section I: Individual Information\n## Section II: Disclosing Entity and Recipient\n## Section III: Reason and Health Information to Disclose\n## Section IV: Effective Period, Revocation, and Expiration","[{\"question\":\"What information must be completed in Section I of the authorization form?\",\"answer\":\"Section I collects the individual’s name, date of birth, social security number, and address details.\"},{\"question\":\"What does Section II ask for regarding disclosure and receiving entities?\",\"answer\":\"Section II requires the disclosing entity (covered entity) information and identifies the recipient and their contact information.\"},{\"question\":\"How does the form handle the authorization period, revocation, and expiration?\",\"answer\":\"The form states the authorization remains effective until revoked or until the specified expiration date or event; if none is provided, it expires in one year. It also explains that revocation must be submitted in writing to the disclosing entity.\"}]","Health Information Disclosure Authorization Form - Release Details | PDF"]