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The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. Keep a copy of this completed form for your personal records.Authorization to Release Personal. Information. Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an. Complete "Inquiry On" section. 8. As an individual requesting your own record, you may obtain a 3 year, 5 year, or complete driving record. This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health information. Alternatively, you can use our builder with step-by-step guidance to get the complete document. Complete this form to authorize the release of personal, individually identifiable information on your account to others (i.e. This law was enacted to protect individuals from unauthorized disclosure of personal information without their consent.