Medical Release of Information Form – Example

Last reviewed: 10/02/2023

Using this Form

To use this medical release form you need to check with your State Health and Human Services Agency and request a form valid in your state, and ensure that you complete all of the sections.

HIPAA Compliance: This form is designed to be HIPAA compliant, but it is important to ensure that you are following all relevant HIPAA regulations, state laws, and healthcare facility policies when releasing medical information.

Expiration Date: Specify an expiration date for the authorization. In most cases, it should not exceed one year, but you can adjust it based on your specific needs.

Witness: Some states may require a witness to the patient’s signature. Check your state’s laws to determine if this is necessary.

Retain a Copy: Make sure to provide the patient with a copy of the signed release form for their records.

Consultation: It is advisable to consult with legal counsel or a HIPAA compliance expert to ensure compliance with any specific state or institutional requirements.

Release of Medical Information Authorization Form

Patient Information:

  • Patient’s Full Name: ________________________________
  • Date of Birth: ________________________________
  • Address: ________________________________
  • City: ________________________________
  • State: ________________________________
  • Zip Code: ________________________________
  • Phone Number: ________________________________

Description of Information to be Released:

  • Complete Medical Records
  • Specific Medical Records (please specify): ________________________________
  • Lab Results
  • Radiology Reports
  • Consultation Notes
  • Other (please specify): ________________________________

Recipient Information:

  • Name of Recipient: ________________________________
  • **Relationship to Patient (if any): ________________________________
  • Address of Recipient: ________________________________
  • City: ________________________________
  • State: ________________________________
  • Zip Code: ________________________________
  • Phone Number: ________________________________
  • **Fax Number (if applicable): ________________________________

Purpose of Release:

  • For the patient’s own use
  • For continuity of care to another healthcare provider
  • For legal purposes (please specify): ________________________________

Authorization and Consent: I, the undersigned, hereby authorize the release of my medical information as described above to the recipient specified. I understand that this information may include sensitive and confidential health records. I further understand that this release of information is voluntary, and I have the right to revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

Expiration Date: This authorization will expire on [insert expiration date, not to exceed one year from the date of signing] unless otherwise specified.

Patient’s Signature: ________________________________ Date: ________________________________

Witness (if required by state law):

  • Name: ________________________________
  • Signature: ________________________________
  • Date: ________________________________