Medical records release form
Authorize the release of medical records to a person or clinic.
A medical records release form is your written permission for a clinic or hospital to share your health records with someone you name. Health privacy law in Canada and the US requires that permission to be specific, which is why this form asks what, to whom, why, and until when.
Opens a fillable version in your browser. Free, no account, nothing uploaded.
Fields in this form
- Patient name
- Date of birth
- Release records from (provider)
- Release records to
- Records to be released
- Purpose
- Authorization expires on
- Signature
- Date
About the medical records release
A medical records release form gives permission for a clinic or hospital to share your health records with a named person or organization. It records who is authorized, what is being released, and for how long.
This fillable version lets you complete it on screen and download a clean PDF to submit to your provider.
When you need it
- Switching to a new doctor or clinic.
- Sharing records with a specialist or family member.
- A request for records needs written authorization.
Where it stands legally
United States: under the HIPAA Privacy Rule (45 CFR 164.508) a valid authorization must describe the information to be disclosed in a specific and meaningful way, name who may disclose it, name who may receive it, state each purpose, include an expiration date or event, and be signed and dated. It must also tell you that you can revoke it in writing and whether treatment or payment can be conditioned on signing. This template has a field for each core element; the revocation and conditioning statements should be added in the records field or attached.
Canada: health privacy is provincial. Ontario's Personal Health Information Protection Act (PHIPA), Alberta's Health Information Act, BC's rules and others all require your consent before a custodian releases your records to a third party, and they give you a right to access your own records. Providers often have their own release form; if they do, use it and keep this one for your records.
A release for records is not a substitute decision document. If you want someone to make health decisions for you, that is a power of attorney for personal care (Ontario) or a health care directive elsewhere.
Providers may charge a reasonable fee for copies, and some records (psychotherapy notes in the US, for example) need a separate authorization.
General information, not legal advice. Rules differ by province, state and city, and they change. Confirm the current rule where the document will be used.
What each field means and how to fill it
| Field | What it means | How to fill it |
|---|---|---|
| Patient name | Whose records they are. | Full legal name as on the health card or insurance. |
| Date of birth | Identifies the right patient. | Day, month, year. |
| Release records from (provider) | The custodian holding the records. | Clinic or hospital name, department and address. |
| Release records to | The recipient. | Name, organization and address. Say how to send: secure fax, portal or mail. |
| Records to be released | Exactly what is covered. | Date range and type: visit notes, lab results, imaging reports, medication list. Say if mental health, substance use or HIV information is included, since some laws need explicit permission for those. |
| Purpose | Why the records are needed. | Continuing care, insurance claim, legal matter, personal use. One line is enough. |
| Authorization expires on | When permission ends. | A date or an event (on completion of my claim). Without an end, US authorizations are invalid. |
| Signature and date | Your consent. | Patient signs. A parent, guardian or attorney for personal care signs for someone who cannot, and should note their authority. |
How to fill this out
- 1Enter the patient's name and date of birth.
- 2Name the provider holding the records and the person or organization receiving them, with a secure delivery method.
- 3Describe the records by type and date range, and flag any sensitive categories you intend to include.
- 4State the purpose and an expiry date or event.
- 5Sign and date, download the PDF, and send it to the provider through their secure channel.
Common mistakes to avoid
- Writing all records with no date range, which some providers will refuse or which releases more than you intended.
- No expiry, which makes a US authorization invalid.
- Sending the signed form by ordinary email with your health card number on it.
- Signing for a family member without authority to do so.
- Forgetting that the release does not force the provider to send records immediately; ask about their turnaround.
- Asking for records to go to a new doctor without checking that the new office can receive them securely.
What makes it hold up, and when you need a lawyer
Usually fine with this template
- Moving to a new doctor or clinic and sending your history ahead.
- Sharing results with a specialist, a therapist or a family caregiver.
- Insurance and benefits claims, and legal matters where your lawyer needs the file.
Use the official form or get advice
- Records of a deceased person, which follow estate rules.
- Records requested by an employer, insurer or investigator; check what you are required to give before signing.
- Court or tribunal matters where a subpoena or a court order is the correct route.
- Records of a child in a custody dispute.
Worked example (illustrative)
Made-up names and figures to show what a completed medical records release looks like. Not a real transaction.
| Medical records release, illustrative | |
|---|---|
| Patient | Samuel Adeyemi, born March 3, 1985 |
| Release from | Riverside Family Practice, 200 Example Avenue |
| Release to | Dr. L. Chen, Northside Clinic, by secure fax |
| Records | Visit notes, lab results and medication list from January 1, 2023 to date. No mental health records. |
| Purpose | Transfer of care to a new family doctor |
| Expires | December 31, 2026 |
| Signed | Patient, October 9, 2026 |
Related official forms, tools and guides
- Medical records release form guide
- Medical power of attorney form: for decisions, not just records
- Power of attorney template
- Redact PDF: black out details before sharing a copy
- Protect PDF: password-protect the file before sending
- Healthcare PDF tools
Frequently asked questions
Why do I need a records release form?
Health providers need your written permission before sharing your records with someone else. Privacy law in Canada and the US requires that permission to say what is released, to whom, why and until when. This form is that permission.
Can I limit what is released?
Yes. Use the records section to specify the types and date range, and to exclude anything you do not want shared.
Does the form expire?
It should. Set a date or an event. In the US an authorization without an expiration is not valid under HIPAA.
Can I cancel it?
Yes, in writing to the provider, for any records not yet released.
Is my information private here?
The form is filled in your browser and not uploaded. Submit the completed form to your provider through a secure channel, and consider password-protecting the PDF.
Will the provider use their own form?
Many do. If so, use theirs. This template helps you know what to expect and works where no form is provided.
Sources checked
- 45 CFR 164.508, Uses and disclosures for which an authorization is required (HIPAA) (core elements and required statements)
Checked 2026-09-19. This page is general information and not legal, tax or financial advice.