How to Complete an Authorization Form

A valid authorization must be written in plain language and contain the following elements:

1. A description of the information to be used or disclosed.
2. The identification of the person authorized to make the requested use or disclosure.
   (The name of the entity/person that will be releasing the records)
3. The name of the person to whom the entity may make the requested use or disclosure.
   (The name of the entity/person that will receive the records)
4. A description of each purpose of the requested use or disclosure. The statement “at the request of the individual” is a sufficient description of the purpose when an individual initiates the authorization and does not elect to provide a statement of the purpose.
5. An expiration date or an event that triggers expiration. The statement “end of the research study,” “none,” or similar language is sufficient if the authorization is for research, including for the creation and maintenance of a research database or research repository.
6. A statement that the individual has a right to revoke the authorization, with exceptions identified, and a description of how revocation may be done.
7. A statement that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer is protected by this rule.
8. Signature of the individual and date.
9. If the authorization is signed by a personal representative of the individual, a description of the representative’s authority to act for the individual.
10. You may request to release a copy of your medical records to another provider through MyChart (Access menu, Questionnaires, then select Patient requested release of information).