Information Release Form

An Information Release Form is required to make public someone’s personal records. In case of research subjects the form is mandatory before the results of the research are made public. The subject gives permission for releasing of his personal details, medical history, test results concerning him and any such relevant topic. In case of a study related to drug or alcohol abuse the subject gives permission to release confidential information regarding his treatment.

Sample Information Release Form

I, ____________________________, authorize _______________________________________ to access and disclose the following information __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The stated purpose for the program being_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I give my consent for the duration of ______________________________________________________________________________

I understand that my records are protected under Federal Rule____________________________

and that I hold the right to revoke the agreement at any given point of time if it concerns my health and welfare. The following information can not be disclosed without my written consent and if done so will be considered a violation of my civil rights. This information will be listed only in the above mentioned program and will not be used for any other purpose. My consent in this event expires on ______________________________________ .

Signature of participant        _____________________________________________________

Date                          _____________________________________________________

Witness 1                                                   Witness 2

____________________                                       _______________________

____________________                                       ________________________

Category: Release Forms