Printable blank authorization to release information form

Release of Information Form

This is a consent for release of information (hereinafter referred to as the “Release of

Information”) about:

_______________________________________________________________________

Name of Individual

_____________________________

_____________________________

Social Security Number

Date of Birth

I authorize __________________________ to release or obtain (circle one) the following

specific information:

_______________________________________________________________________

_______________________________________________________________________

This information may be used only for the following purposes:

_______________________________________________________________________

_______________________________________________________________________

This Release of Information is valid until __________________________. This Release

of Information is not automatically renewable. It expires automatically at the end of the

period specified unless revoked in writing sooner.

I understand I have the right to see this information at any time. I understand that I can

revoke this consent in writing to both the person giving and the person receiving the

information. Any information already released may be used as stated on the consent. By

my signature below, I affirm that I have read this release or it has been read to me, and I

understand its content.

_________________________________

_________________________________

Individual’s Printed Name

Witness Printed Name

_________________________________

_________________________________

Individual’s Signature

Witness Signature

_________________________________

_________________________________

Date

Date

©

TEMPLATEROLLER.COM

Release of Information Form

This is a consent for release of information (hereinafter referred to as the “Release of

Information”) about:

_______________________________________________________________________

Name of Individual

_____________________________

_____________________________

Social Security Number

Date of Birth

I authorize __________________________ to release or obtain (circle one) the following

specific information:

_______________________________________________________________________

_______________________________________________________________________

This information may be used only for the following purposes:

_______________________________________________________________________

_______________________________________________________________________

This Release of Information is valid until __________________________. This Release

of Information is not automatically renewable. It expires automatically at the end of the

period specified unless revoked in writing sooner.

I understand I have the right to see this information at any time. I understand that I can

revoke this consent in writing to both the person giving and the person receiving the

information. Any information already released may be used as stated on the consent. By

my signature below, I affirm that I have read this release or it has been read to me, and I

understand its content.

_________________________________

_________________________________

Individual’s Printed Name

Witness Printed Name

_________________________________

_________________________________

Individual’s Signature

Witness Signature

_________________________________

_________________________________

Date

Date

©

TEMPLATEROLLER.COM

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