Medical Records Release Form for the United Kingdom

Medical Records Release Form Template for United States

A Medical Records Release Form is a legal document used in the United States that authorizes the disclosure of an individual's protected health information (PHI) from one party to another. The form must comply with HIPAA regulations and applicable state laws, containing specific elements required by federal law including patient identification, description of information to be released, purpose of disclosure, expiration date, and clear statements about the patient's rights. This document serves as a safeguard for patient privacy while facilitating necessary information sharing between authorized parties.

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What is a Medical Records Release Form?

The Medical Records Release Form is essential for maintaining patient privacy while enabling necessary information sharing in healthcare settings. This document is required whenever protected health information needs to be shared with parties other than the original healthcare provider, whether for continuing care, insurance purposes, legal proceedings, or personal records. The form must comply with HIPAA regulations and state-specific requirements, ensuring proper authorization for the release of sensitive medical information. It includes detailed patient information, specific records to be released, intended recipient, purpose of disclosure, and duration of authorization.

What sections should be included in a Medical Records Release Form?

1. Patient Information: Full legal name, date of birth, address, contact information, medical record number

2. Healthcare Provider Information: Name and contact information of the provider/facility releasing the records

3. Recipient Information: Name and contact information of person/entity receiving the records

4. Information to be Released: Specific description of medical information to be disclosed

5. Purpose of Release: Stated purpose for the release of information

6. Duration/Expiration: Specific date or event when authorization expires

7. Rights and Notifications: Statement of patient rights including right to revoke authorization

8. Signatures: Patient or authorized representative signature and date

What sections are optional to include in a Medical Records Release Form?

1. Specific Authorization for Sensitive Information: Additional authorization for HIV, mental health, or substance abuse records - use when releasing sensitive medical information protected by special privacy laws

2. Witness/Notary: Space for witness signature or notary stamp - use when required by state law or institutional policy

3. Fee Information: Details about any costs associated with records release - use when the provider charges fees for record copying

What schedules should be included in a Medical Records Release Form?

1. Fee Schedule: Detailed breakdown of applicable fees for record copying and delivery

2. State-Specific Addendum: Additional requirements or notifications required by specific state laws

3. Instructions Sheet: Guidance for completing the form and processing timeframes

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

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Healthcare
Insurance
Legal
Research

Relevant Teams

Medical Records
Compliance
Legal
Privacy Office
Administrative Services

Relevant Roles

Medical Records Administrator
Healthcare Privacy Officer
Medical Office Manager
Compliance Officer
Healthcare Attorney

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What is a Medical Records Release Form?

What sections should be included in a Medical Records Release Form?

What sections are optional to include in a Medical Records Release Form?

What schedules should be included in a Medical Records Release Form?

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