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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. Your authorization allows the.Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. Authorization for Release of Information. Member Information to Be Released. Include the following information about the member whose protected information is being disclosed: 1. Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an. Please utilize these instructions to help answer any questions that may arise when completing the Authorization. The signature of a minor patient is required for the release of some of these items. Access to your personal health information.