Medical Release Form

Types of Medical Release Forms

Medical release forms differ a little depending on who the patient is and which provider holds the records. Two common kinds of release templates are listed below. Pick the release form template that matches the person whose records you need.

• Child medical release form
• Dental records release form

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.

When Is a Medical Release Form Used?

A medical release form comes up in a few typical situations. Having it ready saves time when a provider, insurer or employer asks for your health records. These are the four most common cases:

• Insurance. An insurance company may use the records to decide whether to accept a claim under a policy or to pay an employee compensation claim.
• A new provider. When a patient changes healthcare providers, the new specialist may ask the old one for the records.
• Personal injury. A person’s records act as proof of the injury and help identify its cause and consequences.
• Work. An employer may ask for medical records to check whether a candidate fits the position, to prevent health risks and disability discrimination, or to record sick leaves.

For medical offices, medical release forms are a lawful way to share details of the health condition of an individual with each other. They should keep track of proper writing and managing of medical release forms as doing this is critical to providing a high level of health care. Along with that, having all of the patients’ medical release forms in place helps them comply with local and federal laws.

Medical Release Forms and HIPAA

This type of release of liability form should comply with the Health Insurance Portability and Accountability Act (the shortened form is HIPAA) – a federal regulation that establishes privacy standards regarding patients’ medical data and protects healthcare data from fraud or theft. The Act limits the number of individuals who can get medical info about a patient from their medical care providers. It is essential to obtain medical release forms compliant with the Act before sharing the patient’s data with other specialists or entities, with some exceptions.

Medical Records Release Fees by State

Providers often charge a fee for copies of medical records, and the amount differs from state to state. Search fees, per-page prices and charges for electronic records or X-rays are the usual items. Ask the provider for the current price before you send payment.

Requesting Someone’s Medical Records: 4 Steps

Asking a provider for records goes faster when you know what to expect. 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.

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.

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.

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.

4. Get the 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?

Often, someone other than the patient is the one who asks for the records. If someone is not mentioned in a medical release form, this person is not legally authorized to access the patient’s medical data.

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.

What a Medical Release Form Can Include

Medical release forms are not all alike. Some let the patient limit the content of the release to one condition or one time period, and some add separate consent lines for sensitive categories of information. Think about these choices before you fill in the form.

Records Covered by the Release

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.

The Receiving Party

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.

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.
  

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.

Consent for Sensitive 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.

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.

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How to Fill Out a Medical Release Form

The steps below follow the FormsPal Medical Release form template you can download on this page. Complete each of the fields in order. A form for release of medical records should be compliant with HIPAA. Type your answers in the PDF editor or print the free form and write by hand.

The screenshots under each step show the FormsPal Medical Release template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.

1. HIPAA Authorization and Release: patient details. Enter the patient’s name, date of birth and Social Security number at the top of page 1.

   

2. Agent and Personal Representative. Write the name, phone number, address and e-mail of the agent. Fill in the Legal Representative line only if one applies. The next section should tell who is authorized to release and/or use the medical data of the patient.

   

3. Information to disclose: initial your choices. Initial the lines for the records you want released: all information, a date range, one condition on the Specify line, or the sexually transmitted disease and AIDS or HIV lines. Leave every other line blank.

   

4. Behavioral health choice and Name of Entity. Initial the behavioral health line if you want those records included. Then enter the name, address, phone number and e-mail of the healthcare provider or covered entity that holds the records.

   

5. Dated and Signature of Patient or Legal Representative. Read the statements above the signature line, then add the date and sign. The line is labeled for the patient or a legal representative.

   

6. Notary public block. Leave the day, month and year lines blank until you sign in front of a notary public. The notary then completes them.

   

How to Sign and Use the Medical Release

Once you complete every field, a few more things are left before the release is ready to use. Follow the steps below to finish the signing process and keep a record of it.

1. Read the whole 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.

2. Sign and date it.

   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.

   
3. Use the notary block. If you use the notary block on page 2, sign in front of the notary public and let them add the day, month and year.
4. Keep copies. Keep a signed copy in a secure place for the patient’s file and give copies to the people named on the form.
5. Send it to the provider. Send the signed form to the healthcare provider or covered entity named on the form, and ask how they prefer to receive the submission. The compliance office can usually point you to the right person.

Frequently Asked Questions

What is a medical release form?

A medical release form is a signed document that tells a doctor, hospital or insurer who may receive a patient’s health records. It is also called an authorization for use or release of health information.

Who can I name on a medical release form?

Patients often name a relative, a spouse, a friend, a lawyer or another health care provider. Write the full name, address and contact details of each person or organization, so the provider knows exactly who receives the records.

Can I download the medical release form as a PDF?

Yes. The free FormsPal release form template is a two-page PDF. Download it and print it, or type your answers in a PDF editor before you print.

What choices does the template give the patient?

The patient initials the lines for the information to release. The template offers these choices, and the patient can leave any line blank:

• All information
• A date range
• One specific condition
• Sexually transmitted disease
• AIDS or HIV
• Behavioral health services

Where does the notary sign?

The notary block is at the bottom of page 2, under the signature line. Leave it blank until you sign in front of a notary public, who then fills in the day, month and year.

What should I do with the signed form?

Keep a copy for your own file and send a copy to the provider named on the form. Ask the provider how they prefer to receive it, for example by mail, fax or a patient portal. If you are unsure, call the provider’s compliance office and ask who handles release forms.

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.

General information, not legal or tax advice.

Jennifer M. Settles

Author & Attorney

With over 25 years of experience as a business and transactional attorney, Jennifer has mastered the craft of closing highly successful deals for her clients. Through her wide-ranging expertise in commercial contracts, real estate transactions, M&A and corporate law, Jennifer secures results that are second-to-none.