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Medical Records Release Form

2 pages•11 fields•HIPAA-ready
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Medical Records Release Form

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Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Phone Number
(555) 867-5309
Release Records To (Name/Facility)
Jane Martinez
Recipient Address
1234 Oak Street, Springfield, IL
Recipient Fax or Email
(555) 867-5309
Purpose of Disclosure
Select an option...
Types of Records to Release
Date Range of Records
03/15/1985
Authorization Expiration Date
03/15/1985
Patient Signature
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The Medical Records Release Form provides a HIPAA-compliant authorization for the disclosure of protected health information. Patients specify exactly which records they want released, to whom, and for what purpose. This structured approach ensures your practice meets federal and state privacy requirements while facilitating necessary information sharing between providers, insurers, and other authorized parties.

The form includes granular control over the types of information being released, including options for general medical records, mental health notes, substance abuse treatment records, HIV/AIDS-related information, and genetic testing results. Patients set an expiration date for the authorization and can revoke consent at any time. Special protections for sensitive record categories ensure compliance with 42 CFR Part 2 and state-specific privacy laws.

Essential for every healthcare practice, this form is used when patients transfer to a new provider, apply for disability or life insurance, pursue legal claims, or simply want copies of their own records. Hospitals, multi-specialty groups, and behavioral health practices rely on this form daily to manage information release requests in a compliant and organized manner.

What's included

  • HIPAA-compliant authorization language
  • Recipient identification and contact details
  • Granular record type selection including sensitive categories
  • Purpose of disclosure specification
  • Authorization expiration date and revocation rights
  • Patient signature with date and witness line

Who uses this template

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

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Phone NumberPhone
Release Records To (Name/Facility)Text
Recipient AddressText
Recipient Fax or EmailText
Purpose of DisclosureDropdown
Types of Records to ReleaseCheckbox
Date Range of RecordsText
Authorization Expiration DateDate
Patient SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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