Authorization Letter For Release Of Medical Records for the United States

Authorization Letter For Release Of Medical Records Template for United States

A formal document compliant with HIPAA and U.S. state regulations that authorizes the release of an individual's medical records from one healthcare provider to a designated recipient. This document includes specific details about the records to be released, timeframe, purpose, and expiration of the authorization, while ensuring compliance with federal and state privacy laws.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.

Download a Standard Template

4.6 / 5
4.8 / 5
Access for free
OR

Alternatively: Run an advanced review of an existing
Authorization Letter For Release Of Medical Records

Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.
Upload your Doc

What is a Authorization Letter For Release Of Medical Records?

An Authorization Letter For Release Of Medical Records is a crucial document in the U.S. healthcare system that enables the transfer of protected health information while maintaining patient privacy rights. This document is required under HIPAA regulations whenever a healthcare provider needs to share medical records with third parties. It serves as a legal safeguard ensuring patient consent and specifying exactly what information can be shared, with whom, and for what purpose. The authorization must meet both federal HIPAA requirements and any additional state-specific regulations regarding medical privacy.

What sections should be included in a Authorization Letter For Release Of Medical Records?

1. Patient Information: Full name, date of birth, address, and other identifying information of the patient

2. Healthcare Provider Details: Name and address of the healthcare provider/facility releasing the records

3. Recipient Information: Name and address of person/entity authorized to receive the records

4. Records Description: Specific description of medical records to be released including date range

5. Purpose Statement: Clear statement of the reason for releasing the medical records

6. Authorization Statement: Formal statement authorizing the release of records and acknowledgment of understanding

7. Expiration: Date or event when the authorization expires

8. Signature Block: Space for patient signature, date, and any required witness signatures

What sections are optional to include in a Authorization Letter For Release Of Medical Records?

1. Substance Abuse Records Authorization: Additional specific authorization for release of substance abuse treatment records (42 CFR Part 2 compliance)

2. Mental Health Records Authorization: Specific authorization for the release of mental health treatment records

3. HIV/AIDS Information Authorization: Special authorization for the release of HIV/AIDS-related information

4. Revocation Rights: Detailed explanation of the right to revoke authorization and process for doing so

What schedules should be included in a Authorization Letter For Release Of Medical Records?

1. Identity Verification Documents: Attached copies of government-issued ID or other required verification documents

2. Legal Authority Documentation: Power of attorney or other documentation proving legal authority to request records (if applicable)

3. State-Specific Requirements Appendix: Additional state-mandated disclosures or requirements based on applicable state law

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

Jurisdiction

United States

Publisher

Genie AI

Cost

Free to use
Industries

HIPAA Compliance: The Health Insurance Portability and Accountability Act of 1996, including Privacy Rule requirements, Security Rule requirements, minimum necessary standard, and patient rights regarding health information

State Privacy Laws: State-specific medical privacy laws, including additional privacy protections, specific requirements for medical record release forms, and state-specific retention requirements

42 CFR Part 2: Federal regulations providing special requirements for substance abuse treatment records and additional privacy protections

HITECH Act: Health Information Technology for Economic and Clinical Health Act requirements, including electronic health record requirements and security breach notification requirements

Mental Health Records Regulations: Special state laws governing mental health records and additional consent requirements

Patient Identification: Mandatory element of the authorization letter that must include clear and accurate patient identifying information

Information Description: Detailed description of what medical information is to be released

Disclosure Purpose: Clear statement of the purpose for which the medical information will be disclosed

Recipient Information: Complete identification of who will receive the medical information

Expiration Date: Specific date or event upon which the authorization expires

Revocation Rights: Statement of the right to revoke the authorization and how to do so

Understanding Statement: Clear statement that the patient understands their rights and the implications of signing

Signature Requirements: Space for patient signature and date, including witness signature if required by state law

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

Find the exact document you need

Military Medical Record Request Form

U.S. legal document for requesting military medical records in compliance with federal privacy laws.

find out more

Employment Background Check Release Form

A U.S. legal document authorizing employers to conduct background checks on job candidates while ensuring compliance with federal and state regulations.

find out more

Phi Consent Form

A U.S. HIPAA-compliant authorization form for the use and disclosure of protected health information.

find out more

Phi Authorization Form

A U.S. HIPAA-compliant form authorizing the disclosure of protected health information to specified recipients.

find out more

Dr Work Release Form

A U.S. compliant medical document authorizing an employee's return to work with specified conditions and restrictions.

find out more

Police Vehicle Release Form

A U.S. legal document authorizing the release of an impounded vehicle from police custody to its rightful owner or representative.

find out more

Authorization For Release Of Protected Health Information Phi

A U.S. HIPAA-compliant authorization form permitting the release of protected health information between specified parties.

find out more

Form For Requesting Medical Records

A HIPAA-compliant form used in the US for requesting personal medical records from healthcare providers.

find out more

Share Medical Information Form

A HIPAA-compliant authorization form used in the United States for sharing protected health information between specified parties.

find out more

Release Of Records Request Form

A U.S.-compliant form used to request and authorize the release of records from organizations or institutions.

find out more

Release Of Information Statement

A U.S. legal document authorizing the controlled disclosure of confidential information between specified parties.

find out more

Release Form From Police Department

A U.S. legal document authorizing police departments to release official records while ensuring compliance with federal and state privacy laws.

find out more

Printable Work Release Form

A U.S. legal document authorizing an employee's return to work following medical leave, including any necessary work restrictions or accommodations.

find out more

Military Dependent Medical Records Request Form

A U.S. military healthcare system form for requesting medical records of military dependents, compliant with federal privacy regulations.

find out more

Medical Records Pick Up Form

A U.S.-compliant form authorizing the release and pick-up of medical records, ensuring HIPAA compliance and patient privacy protection.

find out more

Letter For Medical Records Request

A HIPAA-compliant formal request for medical records under U.S. federal and state laws.

find out more

Generic Dental Records Release Form

A HIPAA-compliant U.S. form authorizing the release of dental records from provider to patient or designated recipient.

find out more

Employee Photo Consent Form Gdpr

A dual-jurisdiction (US/EU) consent form for employee photo usage that complies with GDPR and US privacy requirements.

find out more

Dental Release Of Information Form

A U.S.-compliant legal document authorizing the release of dental records from a provider to specified recipients while maintaining HIPAA compliance.

find out more

CT Medical Records Release Form

A HIPAA-compliant authorization form used in the U.S. to permit the release of medical records to designated recipients.

find out more

Consent For Use And Disclosure Of Health Information Form

A U.S. HIPAA-compliant authorization form allowing healthcare providers to use and share protected health information.

find out more

Authorization To Release Rental History

A U.S. legal document authorizing the release of tenant rental history information while complying with federal and state privacy laws.

find out more

Authorization To Release Credit Information Form

A U.S. legal document granting permission to access an individual's credit report and financial information, compliant with FCRA and state privacy laws.

find out more

Authorization To Disclose Medical Information Form

A U.S. HIPAA-compliant form authorizing the release of specified medical information to designated recipients.

find out more

Authorization Release Form For Background Check

A U.S. legal document authorizing employers to conduct background checks on potential or current employees in compliance with federal and state regulations.

find out more

Athletic Medical Release Form

A U.S. legal form authorizing emergency medical treatment for athletes and providing liability protection for healthcare providers and athletic organizations.

find out more

Minor Medical Treatment Authorization Form

A U.S. legal document authorizing medical treatment for minors when parents/guardians are not present.

find out more

Medical Consent Form For Temporary Guardian

A U.S. legal document authorizing a temporary guardian to make medical decisions for a minor when the primary guardian is unavailable.

find out more

Authorization For Release

A U.S. legal document granting permission to share specified information between parties, compliant with federal and state privacy laws.

find out more

Written Authorization To Release Information

A U.S.-compliant legal document authorizing the release of specific personal information between designated parties.

find out more

Workers Comp Medical Release Form

A U.S. legal document authorizing the release of medical information for workers' compensation claims processing.

find out more

Work Release Form Hospital

A U.S. legal document providing medical clearance for employees to return to work, including any necessary restrictions or accommodations.

find out more

Veterinary Medical Release Form

A U.S. legal document authorizing veterinary professionals to provide medical treatment to an animal in the owner's absence.

find out more

Universal Medical Release Form

A HIPAA-compliant authorization form used in the United States for releasing medical records to specified parties.

find out more

Service Release Form

A U.S.-compliant legal document that confirms service completion and releases parties from related future claims or obligations.

find out more

Revocation Of Release Of Information Form

A U.S. legal document used to withdraw previous authorization for sharing personal information, compliant with federal and state privacy laws.

find out more

Release Form For Video Recording

A U.S. legal document granting permission to record and use an individual's image and likeness in video content.

find out more

Records Request Form Medical

A U.S.-compliant form used to request and authorize the release of medical records under HIPAA regulations.

find out more

Public Adjuster Release Form

A U.S. legal document that releases a public adjuster from further obligations upon completion of insurance claim services and receipt of payment.

find out more

Physician Medical Release Form

A U.S. legal document authorizing healthcare providers to release patient medical information in compliance with HIPAA regulations.

find out more
See more related templates

Genie’s Security Promise

Genie is the safest place to draft. Here’s how we prioritise your privacy and security.

Your documents are private:

We do not train on your data; Genie’s AI improves independently

All data stored on Genie is private to your organisation

Your documents are protected:

Your documents are protected by ultra-secure 256-bit encryption

We are ISO27001 certified, so your data is secure

Organizational security:

You retain IP ownership of your documents and their information

You have full control over your data and who gets to see it

2 Docs LeftAccess Now