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1) This Authorization permits the release and use of the personal health information ("PHI") of: Patient's Name: Date of Birth: Last Four Digits of SSN:. The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records.HIPAA Procedure 5031. Authorization Requirements for Use and Disclosure of Protected. The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. If the Authorizations you receive do not contain all 12 items, then the Authorization is not compliant for release of Protected Health Information. HIPAA - Authorization to Disclose Protected Health Information - Mental Health Records ; Form: PDF icon MedRelease2. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, but not limited to:. HIPAA permits providers to disclose PHI with the patient's written consent, provided that the Rule's particular content and other requirements are met.