Release of Information Form

How to Write a Release of Information Form?

A generic Release of Information Form can contain parts that include the following:

1. The Title . The form can start with a title that will state its nature, such as "Release of Information Form," "Information Disclosure Form," or something similar. If you are preparing the document for use by the whole entity, you can put that entity's logo on it as well, or print it on their unique template.
2. Information About the Party Who Is Consenting to Release Information (the Provider of the Consent) . This section of the document is supposed to consist of information that will identify the individual who is giving consent to the disclosure of their personal information (commonly addressed as the provider). It can include their full name, address, telephone number, email address, and more.
3. Information About the Party Who Is Receiving the Consent (the Receiver of the Consent) . Here, you can designate who is being authorized through this form to legally disclose the personal details of the individual who is identified in the previous section of the form. Usually, the name of the authorized entity or individual is enough for this purpose.
4. The Consent to Release Information . You can use this part of the release form to state the details of the information disclosure. Depending on how thorough you want it to be, you can indicate what kind of information can be used and released, what is the purpose of disclosing it, who it can be released to, under which circumstances, and more.
5. The Effective Date of the Release . It is necessary to state the date when the release was signed and the date until when the release is in power. Any information releases that have happened outside the effective period are considered illegal. The date until the information release is effective can also be determined by the occurrence of a certain event, or until the provider revokes it.
6. Other Clauses . Depending on the circumstances under which the Release of Information Form is signed, you can include other parts in it as well. For example, you can include a statement that will determine if the individual wants to cancel the document they need to submit a written revoke form. Or it can include a section with definitions of terms that are used in this document.
7. Signature . The document shall be signed by the provider of the consent. It is necessary to verify their identity and state that they are singing it under free will.

Still looking for a particular template? Take a look at the related templates below:

• Authorization to Release Employee Information;
• Release of Liability Form;
• Photo Release Form.