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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. Marketing or Sale of PHI.By completing and signing this form, I, or my legal representative, agree to allow Aetna to share my PHI with the people or companies listed below. A HIPAA Authorization Form is a document that allows a medical provider to share specific health information with another person or group. All sections must be completed for the authorization to be honored. (Select one per authorization) or write in the facility name and full address, phone and fax number. This form is for use when such authorization is required and complies with the Health Insurance. Massachusetts Department of Public Health. Authorization for Release of Information. (Select one per authorization) or write in the facility name and full address, phone and fax number.