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.
1. 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.
Contact the health provider to find out how much the copying charges will be, if any, and include payment with the signed records release. According to a 2005 article published in PubMed Central, “reasonable costs” for copying records range widely from $2 to $55 for short records of 15 pages and upwards of $15 to $585 for longer records of 500 pages.
2. 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.
When in doubt about whether a records release is needed, get one signed because it will expedite the release of information.
3. Common Situations for Using a Medical Release Form
A patient’s information is often requested for the following purposes:
Insurance: Insurance companies use the 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.
4. 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.
As a reference, a Release is known by other names:
- Medical Authorization
- Authorization to Disclose Health Information
- HIPAA Release
- HIPAA Authorization
5. Medical Records Release Form Sample
You can use one of our free templates (PDF & Word) to authorize the release of medical records.
________________________________________________________________________ ________________________________________________________________________ ___________________________________ ___________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________ ___________________________________ I hereby authorize the following health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription history clearing house, consumer reporting agency, employer, or family member to release (Check one) ☐ all health information about me ☐ my medical records as described on the following page: ________________________________________________________________________ ________________________________________________________________________ ___________________________________ _________________ _________________ ___________________________________ ___________________________________ The following persons/organizations are hereby authorized to receive my entire medical record, treatment record and diagnostic record: ________________________________________________________________________ ________________________________________________________________________ ___________________________________ _________________ _________________ ___________________________________ ___________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________ _________________ _________________ ___________________________________ ___________________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________________ _________________ _________________ ___________________________________ ___________________________________ The following health information that relates to service beginning from ______________________ [Date] to ______________________ [Date], may be released: (Check one) ☐ Entire medical record (including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent by other health care providers) ☐ Only the following: (Check all that apply) ☐ Patient histories ☐ Office notes (except psychotherapy notes) ☐ Test results ☐ Radiology studies ☐ Films ☐ Referrals ☐ Consults ☐ Billing records ☐ Insurance records ☐ Records sent by other health care provide ☐ Other: ___________________________________ I further understand that my medical record may include one or more of the following: (Check all that apply) ☐ Treatment of communicable diseases, including sexually-transmitted diseases, tuberculosis, or hepatitis ☐ Treatment related to AIDS/HIV ☐ Mental health treatment or psychological conditions ☐ Alcohol or substance abuse treatment ☐ Genetic testing ☐ Other: ___________________________________ The above person/organization, its employees, representatives and any other persons performing services for them or on their behalf, may need to obtain, use or disclose any and all information about my physical and mental health, including but not limited to, services for preventative, diagnostic and therapeutic care, tests, counseling, and medical prescriptions for the purpose of: (Check all that apply) ☐ Change of doctor ☐ Individual request ☐ Workers compensation ☐ Specialist referral ☐ Insurance purposes ☐ Continued treatment ☐ Legal investigation ☐ Other: ___________________________________ I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law. This authorization is valid for __________ (Check one) ☐ days ☐ months ☐ years following the date of my signature shown below. A copy, electronic copy, image, or facsimile of this authorization is as valid as the original. I have the right to revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the extent the above person/organization has relied on the use or disclosure of my health information. By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my health does not apply to this authorization. I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.Medical Records Release Form
State of ______________
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Name of Patient
Address
Phone Number
E-mail
Birthdate
___________________________________ Social Security Number
___________________________________
Other Aliases
________________________________________________________________________
Name of Guardian or Legal Representative
Address
Phone Number
E-mail
Person/Organization to Release Information
Street Address
City
State
Zip Code
Phone Number
Fax Number
Person/Organization to Receive Information
Street Address
City
State
Zip Code
Phone Number
Fax Number
Person/Organization to Receive Information
Street Address
City
State
Zip Code
Phone Number
Fax Number
Person/Organization to Receive Information
Street Address
City
State
Zip Code
Phone Number
Fax Number
Patient’s Signature
Patient’s Name
Date
Guardian or Legal Representative’s Signature
Guardian or Legal Representative’s Name
Date
Alternatively, you can use our document builder to create a complete document.
Below is an example of what a completed medical release form looks like. The patient authorizes the releaser to release his medical information to the receiver because the patient is changing doctors.
When considering your health, you may also want to choose someone to be your health agent with a medical power of attorney form.