Medical Records Release Authorization
Authorize the release of your medical records to a person or organization you designate.
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About Medical Records Release
A Medical Records Release Authorization lets you direct a healthcare provider to release copies of your medical records to yourself or to a person or organization you choose. It is a focused way to obtain or transfer your health records.
The form identifies the provider holding the records, the recipient, the records or date range requested, and the reason for the release. It also addresses whether sensitive categories of information are included and how the records will be delivered.
People use this authorization to move records to a new provider, support an insurance or legal matter, or keep a personal copy. Because it releases private health information, it should be specific about what is disclosed and be signed and dated by the patient or authorized representative.
Who needs to complete it
- Patients requesting copies of their own medical records
- People transferring records to a new healthcare provider
- Individuals supporting an insurance or disability claim
- Attorneys or others authorized to receive a patient's records
- Personal representatives requesting records for someone they represent
How to fill out Medical Records Release
- 1Enter the patient name and identifying details.
- 2Identify the provider or facility that holds the records.
- 3Identify the person or organization to receive the records.
- 4Describe the records or date range you want released.
- 5Indicate whether sensitive categories of information are included.
- 6State the purpose of the request and the delivery method.
- 7Note any expiration date for the authorization.
- 8Sign and date the form, or have an authorized representative sign.
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Frequently asked questions
What is a medical records release for?
It authorizes a provider to release copies of your medical records to you or to a person or organization you designate.
How is this different from a HIPAA authorization?
They overlap. A medical records release focuses on obtaining or transferring records, while a HIPAA authorization is a broader permission to use or disclose protected health information.
Is the same form used in every state?
This is a general template. Rules for releasing medical records, including handling of sensitive information, vary by state and provider, so confirm the requirements that apply to you.
Can a provider charge for copies?
Providers may charge a reasonable fee for copying and sending records, subject to the limits that apply where you live.