Medical records release form
Authorize the release of medical records to a person or clinic.
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.
Frequently asked questions
Why do I need a records release form?
Health providers need written permission before sharing your records with someone else. This form is that permission.
Can I limit what is released?
Yes. Use the records section to specify exactly what may be shared.
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.