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Complete all sections of the attached Authorization and Release Disclosure. (DOL-5111). 2. Sign and date the form in the presence of a notary public.This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2. The GEORGIA HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF form is 2 pages long and contains: 2 signatures; 7 checkboxes; 17 other fields. This authorization shall become effective immediately and shall remain in effect until. (date) or for one year from the date of signature if no date is entered. Complete the Authorization to use and disclose protected health information (PDF). Boat owners must carry a Georgia ID, such as a driver's license, and their plastic vessel registration card to show proof of a valid vessel registration. Download and print an Authorization Form for Release of Medical Records and Information. You'll need to complete, sign, and date Grady's medical records release form.