General Authorization For Release Of Information

Summary

GENERAL AUTHORIZATION FOR
RELEASE OF INFORMATION
I, , hereby grant the following organization to release
the information described below from my records

Name of organization:
Address:
City: State: Zip:
Release information to:
Name of organization:
Address:
City: State: Zip:
Information to disclose from my records:
Information will be used/disclosed as follows:
Signature Date of birth Date
Witness Signature Date
This authorization is valid for 90 days from the date of signing

The contents of this document may be eligible for public disclosure. Social Security Numbers are considered confidential information and
will be redacted in the event of such a request. This form is governed by Executive Order 16-01, RCW 42.56, and RCW 40.14

DOC 09-242 (Rev. 02/20/20) Page 1 of 1 DOC 280.500, DOC 390.350, DOC 450.320

Information to disclose from my records: Information will be used/disclosed as follows: Signature Date of birth Date Witness Signature Date This authorization is valid for 90 days from the date …

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Frequently Asked Questions

What is hipaa release of information?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA.

What is consent to release information?

This is sometimes referred to as a “consent,” an “authorization to release,” a “release of information,” or “authorization for disclosure.” The person who signs the release must give informed consent for the information to be disclosed. "Informed consent" means that the person consenting to the disclosure is aware of the confidentiality of the information, the reason for the information request, and how the information will be used.

How to better manage your authorization requests?

• Perform account updates to replace or remove expired card-on-file details
• Submit authorization requests on the optimal day of the week and time of day
• Maintain an informed retry strategy to avoid repeated declines
• Always transmit accurate and complete authorization data
• Identify the specific card types that negatively impact authorization rates

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What does release of information mean?

Release of information (ROI) in healthcare is critical to the quality of the continuity of care provided to the patient. It also plays an important role in billing, reporting, research, and other functions. Many laws and regulations govern how, when, what, and to whom protected health information is released.