The Authorization To Disclose Information document serves as a critical tool for maintaining privacy compliance while enabling necessary information sharing. This document is essential when confidential information needs to be shared between parties in the United States, whether for medical, educational, financial, or other purposes. It ensures compliance with federal regulations such as HIPAA, FERPA, and GLBA, while providing clear documentation of consent and protecting the rights of all parties involved. The authorization typically includes specific details about the information to be shared, temporal limitations, and the purpose of disclosure.
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1. Authorizing Party Information: Details of the person/entity authorizing information disclosure including full name, address, and any identifying information
2. Information to be Disclosed: Specific and detailed description of what information is authorized for disclosure
3. Recipient Information: Complete details of person/entity authorized to receive information, including name, organization, and contact information
4. Purpose of Disclosure: Clear statement of the specific purpose(s) for which the disclosed information may be used
5. Duration and Expiration: Specific timeframe or event that will trigger the expiration of the authorization
6. Authorization Statement: Formal statement of authorization and understanding of rights
7. Signature Block: Space for signature, date, and capacity of signing party
1. Re-disclosure Notice: Required warning about potential further disclosure of information when HIPAA-regulated information is involved
2. Special Categories Authorization: Additional specific authorizations for sensitive information such as HIV status, mental health records, or substance abuse treatment
3. State-Specific Provisions: Additional provisions required by specific state laws based on applicable jurisdiction
4. Electronic Disclosure Consent: Additional consent for electronic transmission of information, if applicable
1. Schedule A - Detailed Information List: Comprehensive itemized list of specific records, documents, or information authorized for disclosure
2. Schedule B - Additional Recipients: List of additional authorized recipients or entities permitted to receive the information
3. Schedule C - Specific Restrictions: List of any specific restrictions or limitations on the use or disclosure of the information
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