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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. This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.A HIPAA waiver of authorization is a legal document that allows an individual's health information to be used or disclosed to a third party. By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above. Print clearly; each section needs to be completed to be valid. 2. Additional Patient Information. Copies released from Health Information Management include medical records only. When is a HIPAA Authorization to Release Medical Information Form Required? To authorize the disclosure of your PHI, please complete and sign the form below and present it to your Health Care Provider, along with the applicable. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient's consent.