Medical Release Form

Types

Child medical release form – This form needs to be used when treating a patient under 18. It is commonly obtained by a competent person who is informed about the child’s issues and medications. It is a useful tool for parents who for certain reasons cannot make medical care decisions on behalf of their child and want to temporarily authorize a trusted person such as the child’s grandparent, step-parent, teacher, friend, etc.

Dental records release form – this is the form in which a patient gives the dentist the right to obtain their dental records from another doctor. The consent should be provided by a dental patient or their legal representative if they are of minor age. The primary purpose of receiving previous medical records of the patient is to provide appropriate dental services to them.

For What Purposes a Medical Release Form Is Used?

There are some typical situations when the form might be needed. First, the form might be important in insurance cases. An insurance company might use it to accept liability under an insurance policy or to consider paying an employee compensation claims. Second, in case a patient changes healthcare providers, the form might be requested from an old specialist by the new one. Third, in personal injury cases, a person’s records act as proof of the injury and help identify the cause and consequences of such. The fourth scenario of the possible usage of the form is by an employer at work: they might need medical records to determine if a candidate fits for the position to prevent health risks and disability discrimination, or to record sick leaves.

Medical Records Release Fees by State

STATES	MAX FEES	STATE LAW
Alabama	Search Fee: $5 Pages 1-25: $1/page Pages 26+: $0.50 Other Documents: Actual cost of reproduction	Alabama Code, Section 12-21-6.1
Alaska	–	No Statute
Arizona	Reasonable Fee	Arizona Revised Statutes, Section 12-2295
Arkansas	Search Fee: $15 Pages 1-25: $0.50/page Pages 26+: $0.25/page	Arkansas Annotated Code, Section 16-46-106
California	Search Fee: $4 Evidence Fee: $15 Pages 1+: $0.10/page Microfilm: $0.20/page	California Evidence Code, Sections 1158 and 1563
Colorado	Search Fee: $18.53 flat fee (first 10 pages) Pages 11 – 40: $0.85 per page Pages 41+: $0.57 per page Microfilm: $1.50 per page	Colorado 6 CCR 1011-1, Chapter 2 Part 5.2.3.4
Connecticut	Pages 1+: $0.65 per page	Connecticut Revised Statutes, Chapter 368v, Section 19a-490b
Delaware	Pages 1 – 10: $2.00 per page Pages 11 – 20: $1.00 per page Pages 21 – 60: $0.90 per page Pages 61+: $0.50 per page Microfilm: actual cost of reproduction	Delaware Code, Title 24, Chapter 17
Florida	Search Fee: $1.00 (per year per request) Pages 1+: $1.00 per page Microfilm: $2.00 per page	Florida Statutes, Section 395.3025
Georgia	Search Fee: $20.00 Pages 1 – 20: $0.75 per page Pages 21 – 100: $ 0.65 per page Pages 101+: $0.50 per page Certification Fee: $7.50	Georgia Code, Section 31-33-3
Hawaii	Reasonable Fee	Hawaii Revised Statutes, Section 622-57
Idaho	–	No Statute
Illinois	Search Fee: $29.48 Pages 1 – 25: $1.11 per page Pages 26 – 50: $0.74 per page Pages 51+: $0.37 per page Electronic Records: 50% of the per page charge for paper copies under subdivision Microfilm: $1.84 per page	Illinois Compiled Statutes, Chapter 735, Section 5/8-2005
Indiana	Search Fee: $20.00 (includes first 10 pages) Pages 11 – 50: $0.50 per page Pages 51+: $0.25 per page Affidavit/Certification: $20.00	Indiana Administrative Code 760, Section 1-73-1
Iowa	Reasonable Fee	Iowa Code, Section 622.10
Kansas	Reasonable Fee	Kansas Statute, Section 65-4971 (REPEALED)
Kentucky	1st Copy: Free 2nd Copy: $1.00 per page	Kentucky Revised Statutes, Section 422.317
Louisiana	Search Fee: $25.00 Pages 1 – 25: $1.00 per page Pages 26 – 350: $0.50 per page Pages 351+: $0.25 per page Max Fee for Electronic Records: $100.00 per request	Louisiana Revised Statutes, Section 40:1165.1
Maine	Search Fee: $5.00 (includes 1st page) Pages 2+: $0.45 per page Max Fee: $250.00 Max Fee for Electronic Records: $150.00 per request	Maine Revised Statutes, Title 22, Section 1711-A
Maryland	Search Fee: $22.88 Pages 1+: $0.76 per page Electronic Records Search Fee: $22.88 Electronic Records Pages 1+: $0.62 per page Max Fee for Electronic Records: $80.00 per request	Maryland Annotated Code, Section 4-304
Massachusetts	Search Fee: $26.36 Pages 1 – 100: $0.89 per page Pages 101+: $0.45 per page Social Security: no charge for request to support a claim under the social security act	Massachusetts General Laws, Chapter 111, Section 70
Michigan	Search Fee: $25.64 Pages 1–20: $1.28 per page Pages 21–50: $0.64 per page Pages 51+: $0.26 per page	Michigan Compiled Laws, Section 333.26269
Minnesota	Search Fee: $19.42 Pages 1+: $1.46 per page X-rays: $10 Search Fee plus the actual cost of reproduction	Minnesota Statutes, Section 144.292
Mississippi	Search Fee: $20.00 Flat Fee (first 20 pages) Pages 21–100: $1.00 per page Pages 101+: $0.50 per page Search/Storage Fee: $15.00 (only charged if records are retrieved from off-site location) Certification Fee: $25.00 Postage and handling: may be added 10% of the total charge	Mississippi Annotated Code, Section 11-1-52
Missouri	Search Fee: $27.13 Pages 1+: $0.62 per page Storage Fee: $25.40 (additional fee if records are retrieved off-site) Max Fee for Electronic Records: $118.85	Missouri Revised Statutes, Section 191.227
Montana	Search Fee: $15.00 Pages 1+: $0.50 per page	Montana Annotated Code, Section 50-16-540
Nebraska	Search Fee: $20.00 Pages: 1+: $0.50 per page X-rays: Actual cost of reproduction	Nebraska Revised Statutes, Section 71-8404
Nevada	Pages 1+: $0.60 per page X-rays: Reasonable Fee	Nevada Revised Statutes,Section 629.061
New Hampshire	Whichever is greater: $15 for first 30 pages or $0.50 per page X-rays: Reasonable Fee	New Hampshire Revised Statutes, Section 332-I:1
New Jersey	Search Fee: $10.00 Pages 1–100: $1.00 per page Pages 101+: $0.25 per page Max Fee: $200.00	New Jersey Administrative Code, Sections 8:43G-15.3 and 13:35-6.5
New Mexico	Pages 1–15: $30.00 flat fee Pages 16+: $0.25 per page X-rays: Actual cost of reproduction	New Mexico Code, Section 16.10.17.8
New York	Pages 1+: $0.75 per page X-rays: Actual cost of reproduction	New York Consolidated Laws, PBH Section 17
North Carolina	Pages 1–25: $0.75 per page Pages 26–100: $0.50 per page Pages 100+: $0.25 per page Minimum Fee: $10.00	North Carolina General Statutes, Section 90-411
North Dakota	Search Fee: $20.00 (includes pages 1-25) Pages 26+: $0.75 per page Electronic Records Search Fee: $30.00 (includes pages 1-25) Electronic Records Pages 26+: $0.25 per page	North Dakota Century Code, Section 23-12-14
Ohio	Search Fee: $20.68 Pages 1–10: $1.36 per page Pages 11–50: $0.70 per page Pages 51+: $0.28 per page X-rays: Search Fee plus $2.30 per page	Ohio Revised Code, Sections 3701.741 and 3701.742
Oklahoma	Search Fee: $10.00 Pages 1+: $0.30 per page X-rays: $5.00 per page Max Fee: $200.00	Oklahoma Statutes, Section 76-19
Oregon	Search Fee: $30.00 (includes pages 1-10) Pages 11-50: $0.50 per page Pages 51+: $0.25 per page X-rays: Actual cost of reproduction	Oregon Administrative Rules, Section 847-012-0000
Pennsylvania	Search Fee: $23.73 Pages 1–20: $1.60 per page Pages 21–60: $1.19 per page Pages 61+: $0.41 per page Microfilm: $23.73 + $2.36 per page	Pennsylvania Consolidated Statutes, Title 42, Sections 6152, 6152.1 and 6155
Rhode Island	Pages 1–10: $2.50 per page Pages 10–50: $0.75 per page Pages 51+: $0.50 per page	Rhode Island Physician Rules and Regulations R5-37- MD/DO, Section 11.2
South Carolina	Search Fee: $26.82 Pages 1 – 30: $0.69 per page Pages 31+: $0.53 per page Max Fee for Electronic Records: $160.94 Max Fee for Paper Records: $214.58	South Carolina Code of Laws, Section 44-115-80
South Dakota	No Fee Schedule	South Dakota Codified Laws, Section 36-2-16
Tennessee	Search Fee: $20.00 (includes pages 1–5) Pages 6+: $0.50 per page	Tennessee Code Annotated, Section 63-2-102
Texas	Search Fee: $49.26 (includes pages 1–10) Pages 11–60: $1.66 per page Pages 61–400: $0.81 per page Pages 401+: $0.44 per page Microform Search Fee: $75.04 (includes pages 1–10) Microform Pages 11+: $1.71 per page Electronic Records Search Fee: $89.24	Texas Statutes, Health and Safety Code, 241.154
Utah	Search Fee: $21.16 Pages 1–40: $0.53 per page Pages 41+: $0.32 per page	Utah Code, Section 78B-5-618
Vermont	Whichever is greater: $5 or $0.50 per page Social Security: no charge for a request to support a claim under the social security act	Vermont Statutes, Title 18, Section 9419
Virginia	Search Fee: $20.00 Pages 1–50: $0.50 per page Pages 51+: $0.25 per page Max Fee: $150.00 X-rays in hard copy format: $10 + actual cost of supplies Electronic Records Search Fee: $20.00 Electronic Records Pages 1–50: $0.37 per page Electronic Records Pages 51+: $0.18 per page Electronic Records Max Fee: $150.00 (or $160 for any request made on or after July 1, 2021) X-rays in electronic format: $10 + $25 per series Microfilm Search Fee: $20.00 Microfilm Pages 1+: $1.00 per page	Virginia Code, Section 8.01-413
Washington	Search Fee: $28.00 Pages 1–30: $1.24 per page Pages 31+: $0.94 per page	Washington Administrative Code, Section 246-08-400
West Virginia	Search Fee : $20.00 Pages 1+ : $0.40 per page Pages 1+ Electronic Records: $0.20 per page Max Fee Electronic Records: $150 Certification Fee: $10	West Virginia Code, Section 16-29-2
Wisconsin	Search Fee: $23.45 Pages 1 – 25: $1.19 per page Pages 26 – 50: $0.89 per page Pages 51 – 100: $0.58 per page Pages 101+ $0.35 per page Microfilm and other media: $23.45 + $1.74 per page X-rays : $23.45 + $11.70 per image Certification (if not patient or their representative): $9.38 per request	Wisconsin Statutes and Annotations, Section 146.83(3f)
Wyoming	–	No Statute

How to Obtain Someone’s Medical Records: 4 Steps

To get your medical history or to do it on behalf of the person who authorized you to get it through a medical release form, you have to take several steps.

Step 1 – Make a request

First of all, it is necessary to get acquainted with the requirements of the medical entity keeping the medical records. Some of them require written requests; others not. For those that require a written form, specify in the document the name of the releasing and receiving parties, the dates of authorization, the details of a part of the medical record (or the entire record) that you need for release, and the date when the right to access comes to an end.

Step 2 – Specify how you would want to get the records

If the receiving party wants to get the records in a certain form, e.g., PDF format to transfer to their flash drive, they should specify it in the request form.

Step 3 – Pay a fee if any

A medical entity might require paying a certain fee for the release of the requested medical data. Smaller medical offices often do not require a fee for printing medical records for someone or sending them to another facility. When it comes to bigger ones, they might require a particular fee, but it cannot be more than the state-approved maximum. For instance, in the state of California, a maximum search fee is $4, and a person cannot be charged more than $0.10 per page when getting the records printed, while in Massachusetts, the highest search fee is $25, and the maximum printing price will depend on the number of pages: the price is $0.84 per page when printing up to 100 pages and $0.43 per page when the number of pages is more than 100. At the same time, some states such as Iowa state that they require a reasonable fee without specifying its amount.

Step 4 – Get necessary medical information

Typically, a medical facility should give access to the requested medical data within 30 days after the request. However, the term might be extended if the medical office sends a letter with the specification of the reason why the delay of the release has happened. Nevertheless, modern facilities try to meet requestors’ needs which is why you can call and ask them about the status of your request after 5-7 business days after sending the request if you haven’t got it yet.

Who Can Use the Patient’s Medical Records?

There is a list of individuals who can receive medical records in the name of the patient with the use of medical release forms. Those can be:

• Attorney-in-fact. This is the person who is specified in the medical power of attorney – the document that is used to authorize someone else to deal with the patient’s medical needs in case they are not able to speak for themselves.
• A caregiver or guardian assigned by the court order. In such a case, the court order or another ruling should be added to medical release forms.
• A legal guardian of a child. This person should be legally appointed to be able to receive medical history on behalf of a child. If medical history is to be obtained to provide certain health care services, consent of the child might be needed which will depend on state laws.
• An administrator appointed by the court/executor of the will of the deceased person. Such a person is authorized to get the medical history of the departed person.

If you need a proper medical release form, you can use one of our templates. We offer you to get medical release forms for free in three different formats. Just select the needed format of a medical release form and download it to your computer.

What Are the Consequences of Violation of HIPAA?

If access to a patient’s medical information is provided without a medical release form, such an act is considered a violation of the HIPPA which might result in a penalty. For example, if a person committing a violation did not know that they are violating the terms of the Act, they might be punished with a minimum fine of $100 and the maximum fine of $50,000 per breach. If a person violates HIPAA due to an act of neglect but the violation is fixed, they will pay a minimum of $10,000 and a maximum of $50,000 for one violation. If the breach is not corrected, the fine will be $50,000.

How to Fill out a Medical Release Form?

A form for release of medical records should be compliant with HIPAA. HIPAA forms divide information into several sections and offer to choose needed options by ticking respective checkboxes.

Step 1 – The patient’s personal information

The medical release form should start with the patient’s print name, date of birth, and Social Security Number.

Step 2 – Agent and the authorities

The next section should tell who is authorized to release and/or use the medical data of the patient. The form has to explicitly indicate whether these individual(s) or approve the medical records release in their entirety or only part of them. It is also up to the patient to decide whether they want their medical release form to give access to medical information that is related only to a certain medical condition or the one that covers a certain period of time.

For instance, the patient might want to release the information about their dental health only or solely about the pregnancy. The types of medical information to be released should be listed explicitly.

Next, the medical release form should mention the recipient(s) to whom the disclosing party can release the patient’s medical data. The information needed in this paragraph of a medical release form is the name of the facility or individual that the patient authorizes their medical history to be released to and addresses along with the contact details.

Step 3 – The purpose

Here, the patient should specify the purpose of authorization. They can write that the purpose is at their request or write down other specific purposes in the medical release form. Among specific purposes might be:

• an insurance claim
• social security certification
• a worker compensation claim
• a request involving a school
• a specialist consultation.
  

Step 4 – Expiration date

Further, one should mention when the authorization provided in the medical release form ends. It might be a particular date or an event.

Step 5 – Signature

Now, it’s time to put a signature and date the medical release form. When filling in the HIPAA form, it is important that the patient reads the rights very carefully before giving their consent. A medical release form should make the patient aware that they are not obliged to reveal their medical records and have the right to revoke their release form at any time.

It is important to make sure the signature of the patient is on the document as, without it, one cannot say that the patient has provided their legal consent.

If the patient is a minor or unable to sign a medical release form, the signature of their legal representative should be put in medical release forms (indicating the age of a minor or the reason why the patient cannot put signature on their own).

If a patient needs to have a medical release form signed by their legal representative, it should be clear what status a signing person has in relation to the patient – relative, legal guardian, court-appointed representative, etc.

Step 6 – Complementary consent for release of medical information

Medical release forms also have a section that lets the patient define whether or not they agree to the disclosing party releasing medical data in relation to a physical or sexual offense, any sort of addictions, STDs, mental health therapies, etc. This section of the medical release form demands a separate signature of the patient or their legal representative. The date of signing is another important element of the document in order to show when the consent or objection was given in the medical release form.

Step 7 – Complementary consent for the release of HIV/AIDS details

The final section in medical release forms makes the patient consent or object to the release of the medical details regarding HIV/AIDS. It should tell whether or not the patient allows the release of these details from their medical history.

This section of the medical records release form should end with the signature of the patient or their representative and the date of signing.

If you need a customized medical release form, use our forms builder. It is devised to help you get a proper medical release form after answering a set of questions. Just select the option that fits you on each of the steps, create an account, and download your custom medical release form to your device.