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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.To pick up my medical record copies. Authorization to Release Information. Fill out the form completely. Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure. A. List the name of what hospital, doctor's office or other healthcare center(s) you were treated at that will be releasing the medical records. I authorize records for the following period of time to be released (must be completed to receive records):. Instructions for completing and mailing this form are on page 2. Completed By Initials : ______ Date: ______. PATIENT. INFORMATION.