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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. The release also allows the added option for healthcare providers to share information.This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2. The signature of a minor patient is required for the release of some of these items. Prepare when a general authorization to release medical information is needed to complete HHSC forms. To protect our patient's confidential medical information we must have a valid, complete and legible authorization to disclose their health information. A. List the name of what hospital, doctor's office or other healthcare center(s) you were treated at that will be releasing the medical records. Instructions for completing and mailing this form are on page 2. I authorize records for the following period of time to be released (must be completed to receive records):. If NO, just complete the Health Care Provider Certification Section below.