Release of Information Template

Release of Information Form
Name Information Owner
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth
MonthDayYear
Date
The information to be released are as follows:
Other
The records to be released are for the purpose of:
Name of Recipient
Address of Recipient
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Effectivity period of this release of information:
Last date of effectivity
MonthDayYear
Date
Does this consent allow to release information to third party?
I understand that this authorization to release the records will remain effective {effectivityPeriod} and in the understanding that the recipient shall use the information in compliance to applicable laws;
This consent {doesThis} the recipient to authorize release of my information to a third party;
This is a standing consent and all information processed shall be limited to what is authorized to be shared by the owner of the information;
Date of Signing
MonthDayYear
Date
Signature
Clear
Should be Empty:

Release of Information Form