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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. Purpose and Laws: This form, when properly completed, permits the release of confidential information about a person receiving services.Your authorization allows the. Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. Member Information to Be Released. Include the following information about the member whose protected information is being disclosed: 1. 477-May a covered entity disclose information created after an authorization was signed. The signature of a minor patient is required for the release of some of these items. Form for the Release of Protected Health Information. All fields must be completed.