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1. Identification of Parties: Details of the record holder and the requesting party
2. Purpose of Release: Clear statement of why the records are being requested and how they will be used
3. Records Description: Specific description of which records are to be released
4. Duration of Authorization: Time period for which the release authorization is valid
5. Authorization Statement: Explicit consent for release of specified records
6. Signature Block: Space for signatures, dates, and any required witnesses
1. Revocation Rights: Statement of right to revoke authorization, used when required by applicable laws
2. Re-disclosure Notice: Warning about potential re-disclosure of information, used for HIPAA-covered records
3. Special Authorizations: Additional authorizations for sensitive information (HIV, mental health, etc.), used when such records are involved
4. Payment Notice: Information about any fees associated with records release, used when applicable
1. Records List: Detailed inventory of specific records to be released
2. Fee Schedule: Breakdown of any applicable fees for records release
3. Authorization Requirements: List of specific requirements for different types of records
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