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Medical Records Release Form

Asks about records to release, release to (Name of person or organization), and release to (Address). Built for patient transfers between healthcare providers.

Questions
11
Page
1
Time
about 3 min

Includes

  • E-signature
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Your practice

Live preview. Tap through it like a patient.

Who it is for

  • Patient transfers between healthcare providers
  • Insurance and disability claim documentation
  • Legal proceedings requiring medical evidence
  • Patient personal copies of medical records

What's inside

  1. Patient NameText · Required
  2. Date of BirthDate · Required
  3. Records to ReleaseCheckbox · 6 choices · Required
  4. Release To (Name of Person or Organization)Text · Required
  5. Release To (Address)Long Text · Required
  6. Purpose of ReleaseMultiple Choice · 5 choices · Required
  7. Expiration Date of AuthorizationDate · Required
  8. I understand that I have the right to revoke this authorization at any time by providing written notice to the practice, and that revocation will not apply to information already released.Toggle · Required
  9. Full NameText · Required
  10. DateDate · Required

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Medical Records Release Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 11 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Medical Records Release Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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