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1. Information Provider Details: Full legal name, contact information, and identification details of the person authorizing the release of information
2. Authorized Recipient Details: Complete details of the third party who is authorized to receive the information, including organization name (if applicable), contact person, and contact information
3. Information to be Released: Specific description of the information authorized for release, including type, scope, and time period of information covered
4. Purpose of Disclosure: Clear statement of the purpose for which the information may be used by the recipient
5. Duration of Authorization: Specific timeframe for which the authorization remains valid, including start and end dates
6. Consent Declaration: Express statement of consent compliant with the Data Privacy Act, acknowledging understanding of the rights and implications
7. Signatures and Date: Space for dated signatures of the information provider and witnesses if required
1. Special Instructions: Additional conditions or restrictions on how the information may be used or shared
2. Revocation Rights: Detailed explanation of how and when the authorization can be revoked, to be included when dealing with particularly sensitive information
3. Medical Information Specifics: Additional sections required for medical information release, including specific health information details and HIPAA-style provisions
4. Financial Information Details: Specific sections for banking or financial information release, including references to the Bank Secrecy Law
5. Digital Authorization Provisions: Additional provisions when the form will be processed electronically, including compliance with the E-Commerce Act
1. Schedule A - Detailed Information List: Itemized list of specific documents or information to be released when the scope is extensive
2. Schedule B - Authorized Personnel List: List of specific individuals within the recipient organization authorized to access the information
3. Appendix 1 - Privacy Notice: Detailed privacy notice explaining how the information will be handled, stored, and protected
4. Appendix 2 - Revocation Form: Pre-formatted form for revoking the authorization if needed in the future
Healthcare and Medical Services
Banking and Financial Services
Education
Insurance
Real Estate
Legal Services
Human Resources
Government Services
Telecommunications
Professional Services
Legal
Compliance
Human Resources
Information Security
Risk Management
Operations
Records Management
Customer Service
Data Privacy
Administrative Services
Data Protection Officer
Compliance Manager
Human Resources Manager
Medical Records Administrator
Legal Counsel
Privacy Officer
Records Manager
Information Security Officer
Risk Manager
Operations Manager
Healthcare Administrator
Bank Manager
School Registrar
Insurance Claims Manager
Customer Service Manager
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