Medical Release Form

A medical release form (which may also be referred to as an authorization for use or release of health information) is a document that is an important element of the medical records of every person. Its aim is to provide access for the defined list of people to information about a person’s health. Commonly, among such people are health care providers, relatives, spouses, friends, etc. If someone is not mentioned in a medical release form, this person is not legally authorized to access the patient’s medical data.

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.

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.


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.

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.

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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 1 to filling out a medical release form - patient info

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 2 to filling out a medical release sample - agent and authorities

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 3 to filling out a medical release template - purpose

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 5 to filling out a medical release example - signature

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.

Published: Mar 23, 2021