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Medical Release Form Template

Easily send and receive your medical release form template online. Send patients record release forms to fill out on their phone, tablet, or computer. Patients securely sign and submit completed forms directly to your account. Track your patient's progress, send automated appointment reminders, and receive completed medical release forms online.
Setup a Medical Release Form
Medical Release Form Template

Medical Records Release Form Template

Give your patients the freedom to complete medical release forms with any device, anywhere. Streamline the way you collect signatures and record release forms by setting up your form online.

Easily personalize this release form template with a HIPAA compliant form builder.

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What is the Medical Release Form?

A medical release form permits healthcare professionals to share patient medical records with other parties.

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An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

HHS.gov

The liability falls on you to handle patient data in a compliant way. Patient privacy is a serious topic, legislation from the Health Insurance Portability and Accountability Act to the Patient Protection and Affordable Care Act place heavy fines on medical professionals who mistreat patient information.

A medical release form does not empower your staff to share patient information with just anyone. Depending on what is included in the form, the document may release medical information to the patient’s family, other doctors, insurance providers, attorneys, or anyone who may make healthcare decisions on behalf of the patient.

What is included in medical release forms?

The goal of the medical release form is to protect yourself from potential liability. These are the main items included in release forms. The elements will vary depending on the specific needs of your practice.

01Patient Information

Your medical release form will require the patient’s information, which will include; the patient’s name, phone number, address, email address, date of birth, social security number, and other identifiable information that is relevant. If a parent or guardian needs to release medical information on behalf of their child, the name and signature of the parent or guardian will need to be included as well.

02Receiving Party

Included on the medical release form will be an area for the patient to state who may access their medical records. This will include the names, titles, addresses, and contact information of the receiving party. Have your patients fill out a new medical release form for each receiving party. Using separate forms will enable you to group separate types of patient information with difference receiving parties.

03Patient Information to be Shared

You may have the patient list the types of information that you need to be shared. This may include tests, results, scans, notes, or images. The patient may limit the information that is shared by condition, date, body part and so on.

04Purpose of the Medical Release

The patient will need to indicate why their medical record is being released. Normal options include; insurance claim, medical disability, college immunization, specialist consultation, social security certification, inform child’s nurse at school, and more.

05Expiration of Authorization

This date will give the patient a record of when their release form expires. Typically, medical release forms will have a default expiration of 90 days. However, you may choose whatever expiration date you would like, but 90 days is the standard. This means you will have to request additional authorization of record release forms as they expire, but this will help protect your business by acquiring more written approval.

06Disclaimers

Give your patient information about their rights and how their medical records will be used. You should tell the patient that they are under no obligation to release their medical records and they can revoke their authorization to release at any time. This is also a good place to mention any fees associated with the release of the record.

07Signature and Date

Have your patients e-sign and date the authorization form. Completed medical records release forms will be submitted directly to your account online. Review authorization of record release forms online.

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FormDr gives your practice everything needed to easily send and receive HIPAA compliant forms online. We help practices who:

  • Are having patients fill out paper forms during the appointment
  • Are emailing patients a PDF or Word Doc to print out, fill out, scan, and send back
  • Are spending time manually printing and scanning paper forms