Table of Contents
- Medical Records Release Form Template
- What is a Medical Records Release Form?
- When to Use a Medical Records Release Form
- Consequences of Not Using a Medical Records Release Form
- Common Release Situations
- What to Included in a Medical Records Release Form
1. Medical Records Release Form Template
2. What is a Medical Records Release Form?
A medical records release is a written authorization for health providers to release information to the patient as well as someone other than the patient. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state laws mandate that health providers not disclose a patient’s information without a valid authorization except in limited circumstances as required or permitted by law.
A simple release form will identify the following basic elements:
- Who will disclose the information and who will receive the information
- What information will be disclosed
- Where information may be disclosed and re-disclosed by the recipient
- When the authorization will expire
- Why the information is being disclosed
- How a patient may authorize and revoke disclosure of information
As a reference, a Release is known by other names:
- Medical Authorization
- Authorization to Disclose Health Information
- HIPAA Release
- HIPAA Authorization
Medical Records Release Form PDF Sample
The sample medical records release form below details an agreement among the patient, ‘Thomas E Beckman’, the person who will releasing the information, ‘Jeane R Gano’, and the person who will be receiving the information, ‘Mark T Landis.’ Thomas E Beckman authorizes Jeane R Gano to release his medical information to Mark T Landis because Thomas E Beckman is changing doctors.Medical Records Release
3. When to Use a Medical Records Release Form
Patient records are the health provider’s primary business records, but they are also confidential records of information in which disclosure is partially controlled by the patient.
You need this form when releasing information NOT related to the following:
- Patient’s Medical Treatment
- Payment for Medical Treatment
- Healthcare Operations
In addition, health providers have a right to charge for the reasonable costs of copying patient records. Many providers want payment before they will release records. Health IT provides an overview of state law and detail the maximum fees doctors and hospitals may charge patients for copies of records.
4. Consequences of Not Using a Medical Records Release Form
Health providers have a duty to ensure that information is released only to properly authorized individuals and organizations. The overarching consequence of not using a release is that the health provider will not release the information. Patients have a right to sue any person who unlawfully releases their information without consent. As a result, health providers will not release any information without a valid records release.
5. Common Release Situations
A patient’s information is often requested for the following purposes:
Insurance: Insurance companies use information to underwrite life and health insurance policies, pay bodily injury claims, and pay workers compensation claims.
Continued treatment: When a patient is referred to a specialist or moves and switches health providers, the new provider will want to review the patient’s history.
Legal: In personal injury cases, records provide proof of physical injuries, help calculate damages, and determine the cause of injuries or, in a medical malpractice case, to determine whether the health provider exercised reasonable care.
Employer: In the workplace, employers conduct pre-employment exams and lab tests that relate to specific job requirements, use medical information to determine job fitness, and document sick leave.
Research: Clinical trials and medical studies use identifiable information to conduct research.
Medicinal Marijuana: Your doctor will likely record a need for medicinal marijuana in your records. If a dispensary needs additional proof, this form may need to be provided.
6. What to Include in a Medical Records Release Form
To be valid, a simple records release must include at least the following:
Authorized Request: The names or other specific identification of the person authorized to make the requested disclosure.
Recipient: The names or other specific identification of the recipient of the information.
Specific Information: A description of the information to be used or disclosed, identifying the information in a specific and meaningful manner.
Risk of Disclosure: A statement of the potential risk that information will be re-disclosed by the recipient and no longer protected.
Expiration: Expiration date or expiration event that relates to the patient or to the purpose of the use or disclosure.
Revocation: A statement of the patient’s right to revoke the authorization.
Purpose: A description of each purpose of the requested use or disclosure.
Refusal to Sign: Whether treatment, payment, enrollment, or eligibility of benefits can be conditioned on the authorization and consequences of refusing to sign the release.
Date and Signature: If the patient’s authorized representative signs the release, a description of the authorized representative’s authority to act for the patient must also be provided.
When considering your health, you may also want to choose someone to be your health agent with a medical power of attorney form.