Sample Forms for Release of Information or Records

These sample forms can be used for release of information or release of records. Please note the following before using these forms:

• These are compliant with either FERPA (Family Educational Rights and Privacy
  Act) for education records or HIPAA and CMIA (Health Insurance Portability and
  Accountability Act and California Confidentiality of Medical Information Act) for
  health records.
• Do not use these forms for release of information or records that may be subject
  to other confidentiality laws, such as certain drug treatment, mental health and
  special education records.
• All forms can and often should be adapted to meet specific needs of a program.
• All forms should be reviewed by legal counsel before use.
• These are not consent to treatment forms.