The Authorization to Release Records is a ready-to-use records & authorization template you can send for signature in minutes. It is written for 1 signer (authorizer) and, by default, expires 14 days after it is sent if left unsigned. It covers waiver, consent, lease, healthcare. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Authorization to Release Records **Date:** ___________ ## Authorizing Party **Name:** ___________ **Address:** ___________ **Date of Birth:** ___________ **Account/Reference Number:** ___________ ## Records Custodian **Organization:** ___________ **Address:** ___________ **Department:** ___________ ## Records to Be Released I hereby authorize the above-named organization to release the following records: **Type of Records:** ___________ **Note:** For medical records, please use the dedicated Medical Records Release form, which includes required HIPAA-compliant authorization language. **Specific Records Requested:** ___________ **Date Range:** From ___________ to ___________ ## Recipient of Records The above records shall be released to: