Form 5459

Prior to the release of PHI that requires authorization, the A/R must complete and sign DHS Form 5459 (rev. 07/2016), Authorization for Release of Information.

Signed, blank Forms 5459 are not permissible and may not be obtained or used for any purpose. Form 5459 may be used to release or obtain information only if the A/R or PR has specified on the Form 5459 to whom information is to be released or from whom information is to be obtained. At the point the A/R signs Form 5459 it must be dated. Form 5459 should be used within 30 days from the date it is signed.