Medical Records Release Form

Medical Records Release Form Template for United States

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Key Requirements PROMPT example:

"I need a Medical Records Release Form for transferring my complete medical history from City General Hospital to my new specialist at Advanced Care Center, with authorization valid until March 15, 2025, including specific permission for sharing mental health records."

Document background

The Medical Records Release Form is essential for maintaining patient privacy while enabling necessary information sharing in healthcare settings. This document is required whenever protected health information needs to be shared with parties other than the original healthcare provider, whether for continuing care, insurance purposes, legal proceedings, or personal records. The form must comply with HIPAA regulations and state-specific requirements, ensuring proper authorization for the release of sensitive medical information. It includes detailed patient information, specific records to be released, intended recipient, purpose of disclosure, and duration of authorization.

Suggested Sections

1. Patient Information: Full legal name, date of birth, address, contact information, medical record number

2. Healthcare Provider Information: Name and contact information of the provider/facility releasing the records

3. Recipient Information: Name and contact information of person/entity receiving the records

4. Information to be Released: Specific description of medical information to be disclosed

5. Purpose of Release: Stated purpose for the release of information

6. Duration/Expiration: Specific date or event when authorization expires

7. Rights and Notifications: Statement of patient rights including right to revoke authorization

8. Signatures: Patient or authorized representative signature and date

Optional Sections

1. Specific Authorization for Sensitive Information: Additional authorization for HIV, mental health, or substance abuse records - use when releasing sensitive medical information protected by special privacy laws

2. Witness/Notary: Space for witness signature or notary stamp - use when required by state law or institutional policy

3. Fee Information: Details about any costs associated with records release - use when the provider charges fees for record copying

Suggested Schedules

1. Fee Schedule: Detailed breakdown of applicable fees for record copying and delivery

2. State-Specific Addendum: Additional requirements or notifications required by specific state laws

3. Instructions Sheet: Guidance for completing the form and processing timeframes

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��ֱ�� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Business Associate

Clauses

Relevant Industries

Healthcare
Insurance
Legal
Research

Relevant Teams

Medical Records
Compliance
Legal
Privacy Office
Administrative Services

Relevant Roles

Medical Records Administrator
Healthcare Privacy Officer
Medical Office Manager
Compliance Officer
Healthcare Attorney

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