Authorization to Disclose Information Completed Form Examples and Samples
Explore professional Authorization to Disclose Information examples and samples. Learn how to automate form completion and data extraction for medical and legal documentation.
Automated Processing of Authorization to Disclose Information Forms
How this form was filled:
This example demonstrates how an AI can parse an informal patient intake narrative to extract specific authorization details. By extracting the patient's full name, medical record details, and the authorized recipient, the AI automates the tedious data entry process typically required for legal and medical documentation.
Source document used: Clinical Intake Coordinator Email
Subject: Patient Intake Details - Marcus V. Holloway - ID #998234-AX Dear Admissions Team, I am writing to confirm the intake details for our new patient, Marcus Vincent Holloway, who is scheduled to begin his diagnostic assessment on February 12, 2026. Marcus has been under my care at the Summit Wellness Center for the past six months. During our last consultation on January 28th, Marcus explicitly requested that we be allowed to share his psychological evaluations and progress summaries with his primary care physician, Dr. Elena Rodriguez. He emphasized that he trusts Dr. Rodriguez completely regarding his long-term health plan and wants her to be looped in on all diagnostic outcomes. We have documented his preference in our internal portal. He has authorized the release of his medical history specifically to Dr. Rodriguez's office at 442 Oak Street, Suite 300, Denver, CO 80202. Please ensure that all correspondence is marked as 'Confidential: Patient Health Information.' Additionally, I’ve noted that Marcus is currently on a specific medication regimen for anxiety, but he requested that we withhold the detailed pharmacy logs from this specific disclosure. If you have any trouble processing these records, please reach out to my assistant, Sarah, at extension 402. We need this authorization form on file before he arrives on the 12th to ensure there are no delays in his care coordination. Thanks for your assistance in getting this paperwork sorted before his first session.
Information used to fill out the document:
- Patient Full Name: Marcus Vincent Holloway
- Patient ID: 998234-AX
- Authorized Recipient: Dr. Elena Rodriguez
- Recipient Address: 442 Oak Street, Suite 300, Denver, CO 80202
- Intake Date: February 12, 2026
What this filled form sample shows:
- Entity extraction from semi-structured narrative text
- Normalization of names and addresses for form fields
- Identification of temporal constraints (intake date vs. document date)
- Contextual awareness of sensitive information scope
- Noise reduction by filtering out administrative metadata
Form specifications and details:
| Form Type: | Authorization to Disclose Information |
| Industry: | Healthcare |
| Compliance Standard: | HIPAA |
| Primary Use Case: | Clinical Data Sharing |
| Categories: | authorization forms |
| Created: | May 25, 2026 09:58 PM |