Privacy Release Form

According to a law a personal release form is required to access a person’s personal information. In case anyone requires information like your social security number, bank account number, driving license, registration, mortgage details etc he or she will have to get your signature on a privacy release form wherein you give permission for your personal information to be made public. You will have to authorize a person or a representative to access those information. It is a waiver that will allow agencies to release any information about you. Suppose you have an insurance case going on and the insurance company requires certain documents to settle your claim. You will have to grant waiver to the company to acquire the required information from the government agencies.

Sample Privacy Release Form

I, ____________________, give permission to ________________________ (name of the agency) to release all information required including birth records, medical certificates that may be relevant to my case to _________________________ (name of the insurance agency) or its representative.

Name        ________________________                Phone no   ______________________

Age   ________________________                Date of birth       ______________________

Address     ________________________        Street        _____________________________

City   ­______________________________      Zip    _____________________________

Contact Number _______________________________________________________________

E-mail address        _________________________________________________________________

Social Security No        ___________________________________________________________

Policy claim no    ___________________________________________________________

Signature   ___________________________   Date  _____________________________

Category: Release Forms