The Authorization to Release Information Form is the Maine Bureau of Motor Vehicles (BMV) form, issued under the Department of the Secretary of State, that records your written permission to release or obtain your medical, vision or driving record information. You use it when the BMV, a health professional or another person or organization needs to share that information with you or on your behalf. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form is published by the Maine Secretary of State, and the BMV says its forms are completed, printed and mailed.
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What is Authorization to Release Information Form – Maine?
The Authorization to Release Information form is a Maine Bureau of Motor Vehicles (BMV) document in which a person gives written permission for medical, vision or driving record information about them to be released to, or obtained from, a named individual or organization.\n\nThe BMV is part of the Maine Department of the Secretary of State. The form is built in four blocks:\n- Whose information will be disclosed: name, driver's license number, date of birth, telephone, address and e-mail.\n- What you want disclosed: driver medical evaluation and other related medical history; vision examination, vision test results or other related medical and vision history; driving record, crash history and driver license status; or another item you specify.\n- Purpose of the disclosure: whether to release your information to, or obtain your information from, a named individual or organization, with its address, telephone and fax, and an optional e-mail address.\n- Authorization: the statement authorizing release by one party to another, the period the authorization covers, your signature and the date.\n\nThe authorization states that the information may be shared with any qualified healthcare professional who submits information about the disclosed medical history to determine your eligibility for a driver's license. The BMV's forms page also lists the CR-24 Medical Evaluation Form and the MVE-103 Eye Examination Form among its resources for medical and vision matters; this authorization is a separate document.
Who needs to file Authorization to Release Information Form – Maine?
The main user is the person whose information will be disclosed: the form's first block asks for that person's name, driver's license number, date of birth and contact details, and the signature at the bottom is the authorization itself.\n\nYou would use it when you want your medical history, vision history, or driving record, crash history and driver license status released to a person or organization, or obtained from one. The form lets you mark either direction: Release my information to or Obtain my information from.\n\nThe form also states that the information may be shared with any qualified healthcare professional who submits information about the disclosed medical history for the purpose of determining your eligibility for a driver's license.\n\nThe form has no separate signature line for a parent, guardian or representative, and it does not say who else may sign for you. Questions about those cases go to the BMV at (207) 624-9000; TTY users call Maine relay 711.
When to file Authorization to Release Information Form – Maine
Complete the form when you want the BMV, a health professional or another named party to release your information or obtain it for you. The form sets no due date of its own.\n\nThe authorization has its own time frame, which you write on the form: the From and To dates in the authorization statement. The form remains in effect for that period unless you cancel it in writing at an earlier date.\n\nIf you want to end the authorization before the To date, the form says the cancellation must be made in writing by you.
How to fill out Authorization to Release Information Form – Maine
Enter whose information is disclosed
Print your name, driver's license number, date of birth, telephone, address and e-mail in the first block, Whose information will be disclosed?
Check what you want disclosed
Check all boxes that apply: driver medical evaluation and related medical history; vision examination, test results or related history; driving record, crash history and driver license status. Use Other (please specify) for anything else.
Choose release or obtain
Under the purpose of the disclosure, check Release my information to or Obtain my information from.
Identify the individual or organization
Enter the name of the individual or organization, its address, town or city, state or province, zip code, telephone and fax.
Decide on e-mail delivery
If you want information sent by e-mail, initial the risk statement at INITIAL HERE and print the e-mail address where it should go. Leave this section blank if you do not want e-mail delivery.
Complete the authorization statement
Enter who releases the information and who receives it in the blanks after "I hereby authorize the release of my information by" and "to". Read the statement about sharing with a qualified healthcare professional.
Set the period of authorization
Write the From and To dates for which the form remains in effect. You can cancel earlier only in writing.
Sign and date the form
Sign on the Signature line and enter the date.
Review and download the completed PDF
Check that every block matches your intent, then download or print the completed PDF from FillingPDF and mail it as described under How to submit.
How to submit Authorization to Release Information Form – Maine
The BMV says its forms cannot be submitted online: complete the form, print it, and mail it to the address on the document.\n\n- By mail: the address printed on the form is Bureau of Motor Vehicles, 29 State House Station, 101 Hospital Street, Augusta, ME 04333-0029.\n- Questions: call (207) 624-9000. TTY users call Maine relay 711.\n\nSign and date the form before sending it. If you want information sent by e-mail, initial the e-mail risk statement and print the address where it should be sent; the e-mail option is optional.\n\nThe BMV also notes that Microsoft Edge may have trouble opening or filling these PDFs and suggests another browser such as Chrome or Firefox. FillingPDF lets you fill out and download the PDF; submission follows the BMV's mail instructions above.
Common mistakes to avoid
- Leaving the contact details in the first block unprinted or hard to read; the form asks you to print clearly.
- Checking nothing under the disclosure list instead of checking all that apply or listing the information specifically in the Other line.
- Not marking whether you want to release your information to someone or obtain your information from someone.
- Giving an e-mail address for delivery without initialing the e-mail risk statement beside INITIAL HERE.
- Leaving out the From and To dates, so the period the authorization stays in effect is unclear.
- Sending the form without your signature and the date.
- Trying to submit the form online when the BMV says its forms must be completed, printed and mailed.
- Trying to cancel the authorization by phone or e-mail when the form says you must cancel it in writing.
Frequently asked questions
What is the Authorization to Release Information Form?
It is a Maine Bureau of Motor Vehicles form in which you authorize medical, vision or driving record information about you to be released to, or obtained from, a named individual or organization. The form also covers sharing with a qualified healthcare professional reviewing your driver's license eligibility.
What information can I authorize to be released on this form?
You can check driver medical evaluation and related medical history; vision examination, vision test results or related vision history; and driving record, crash history and driver license status. A fourth option, Other, lets you list something specific.
Can I submit the authorization to release information form online?
No. The BMV states that its forms cannot be submitted online and must be completed, printed and mailed to the address on the document. The address printed on this form is 29 State House Station, 101 Hospital Street, Augusta, ME 04333-0029.
How long does the authorization stay in effect?
It stays in effect for the period you write in the From and To dates on the form, unless you cancel it in writing at an earlier date. The form does not set a fixed length of its own; you choose the dates.
How do I cancel my authorization before it ends?
The form says it remains in effect unless you cancel it in writing at an earlier date. Send a written cancellation to the BMV; for questions, call (207) 624-9000, or Maine relay 711 for TTY users.
Do I have to give an e-mail address on the form?
No, e-mail is optional. If you want information sent by e-mail, initial the statement that e-mail and the internet carry risks the sharing office cannot control, and print the address where you want information sent.
Can I fill out this form online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not send the form to the BMV; you mail it yourself following the BMV's instructions.
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