Free Medical Records Release Authorization Forms (HIPAA)

The Medical Records Release Authorization is the disclosure of the members of the family or next of kin to whom a person would wish to have access to his medical records.

Medical records are very confidential pieces of documents that are kept off the public limelight ordinarily. In 1996, a federal law was specifically passed to safeguard these records from arbitrary public access. This was the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It, alongside a host of state laws, bind healthcare providers from disclosing records arbitrarily without the patient signing any forms to authorise the same.

It also stipulates some rights for the patients concerned to understand how the information regarding their health shall most likely be used later. Its major goal is the proper protection of the health records of individuals and other third parties.

This form goes by several other names. Below are but a few of them:

  • Medical Record Release Form
  • Medical Release Form
  • HIPAA form
  • Medical Authorization Form

As per the act, only those who have been expressly mentioned can access the medical records contained in the authorization form. They have to reveal themselves first and foremost before being granted access to medical records. Closely related to this is the extent to which they might access the prevailing records. The patient has the prerogative to limit each named person to specific portions of the information. For instance, a parent might gain more information compared to distant kin.

Free Templates

Free Customizable Authorization Generic Medical Records Form as Word Document

Free Downloadable HIPAA General Release of Information Form as Pdf File

Free Downloadable Authorization to Disclose Health Form as Pdf File

Free Downloadable HIPAA Authorization to Release Medical Information Form as Pdf File

Free Downloadable HIPAA Authorization for Patient Form as Pdf File

Free Customizable HIPAA Authorization of Health Information Form as Word Document

    HIPAA Forms – By Types

    There are several types of HIPAA forms that one can download and use for different cases. Here are some different types of HIPAA forms:

    • Dental (ADA) HIPAA form– It is used to authorise a dental practitioner to release a patient’s records while working within the legal boundaries of HIPAA compliance.
    • Chiropractic HIPAA form– It is used to authorise a chiropractor to determine the most appropriate and helpful chiropractic treatment.
    • Medicare HIPAA (CSM 10106)– It is used to advise Medicare of the individual(s) one has chosen to have access to their personal health information
    • Medical Release HIPAA form– It is used to allow an appointed person or party to share specific health information with another group or person.
    • Health Care Coverage and Payment Request Form– It is used to authorise the release of any information to aid in processing a claim and certifies that the information provided is true, accurate, and complete.

    Common Situations to Use this Form

    Some situations warrant the use of HIPAA forms- situations that require the disclosure of an individual’s personal information. Such situations include:

    • Insurance: Insurance companies usually use the information to determine whether an individual is eligible for life and health insurance policies or not. They also use the information to pay bodily injury claims that their insured files and pay workers’ compensation claims.
    • Research: There are instances when a patient’s personal health information may be required for research purposes. For the information to be released for research purposes, it is essential for the health care provider or the person in charge of the patient’s information to remain HIPAA compliant to avoid any litigation.
    • Medical marijuana: In states, when medical marijuana is approved, a health worker such as a doctor, nurse, caregiver, or any other person with authority may be required to share a patient’s personal information with a third party for them to be approved to use medical marijuana. Therefore, to ensure that one remains HIPAA compliant, it is vital to have the patient fill out a HIPAA form for proper authorization.
    • Litigation: The records may be ordered for access by a court of law. They may be used for furnishing evidence of the health status of the accused or as a supporting document on any argument within a court of law. Also, the records may serve as an alibi in the case of mistaken identity.
    • Settlement of heath fees: If seeking support from an insurance provider to the settlement of health fees, the records may yet again come in to aid in determining how much to pay and how to pay them. That is because they provide a breakdown of the costs involved in mitigating specific health conditions and how much they accrue collectively.
    • Employers: Employers may also require the forms if they want proof that their employers were indeed out of work deservingly. If the employer runs a health scheme for the employees, it may rely on these forms to prove that the employee was indeed hospitalized. This also determines how much to pay and whom to pay.

    Basic Requirements of HIPAA

    In order for the medical records release authorization form to be deemed valid as per the HIPAA standards, it has to contain some bare minimum set of information. The following are the core pieces of information it has to provide:

    • Patient’s full name
    • Date of birth of the patient
    • Medical record number assigned to him by the healthcare facility
    • Address – Both postal and physical address. These addresses are for the residences rather than the workplaces of the patients
    • Phone number of the patient
    • List of all those who are authorised to access the medical records of the patients concerned


    As per the HIPAA rules, this form shall be deemed incomplete not unless it contains all the information stipulated above. This might call for any amendments until the bare minimum threshold is finally attained.

    Patient records and other related health records are usually very crucial. This is why it is essential always to use HIPAA form to prevent disclosing such information to third parties.

    Here are some of the things that must be included in this authorization form:

    • Authorised Request – The names and identities of the persons who are authorised to seek access to the health records.
    • Recipient – Identities of the other persons who may have a right to access the information.
    • Specific Information – A description of the specific piece of information to be disclosed to or used by a person.
    • Risk of Disclosure – The potential harm, damage, or danger that the disclosure is more likely to inflict.
    • Expiration – An ultimatum or deadline within which the authorization may be effective.
    • Revocation – A written statement by the patient himself authorising the surrender of his rights.
    • Purpose – Descriptions of the exact purposes of the disclosure itself.
    • Refusal to sign – The form should outline whether the treatment, enrollment, payment, or eligibility of benefits can be based on the approval and also consequences of refusing to sign the release.
    • Date and Signature – Date when the authorization was made and the signature vouching for such an authorization.

    Free HIPPA Forms : By State

    There are legal considerations that must be factored in when preparing or filling HIPAA forms. These considerations are important as they help govern the release of personal health information to a third party.

    These legal considerations include:

    • 45 CFR Part 160 : The Privacy Rule 45 CFR Part 160 provides the first comprehensive federal protections for the privacy of health-related information. This rule is carefully balanced to offer strong privacy protections that do not interfere with patient access to or their quality of health care delivery.
    •   CFR Part 164: CFR Part 164 law required that those handling a patient’s personal health information implement and use appropriate safeguards and measures to prevent the disclosure of such information and comply with all security requirements of the HIPAA Security Rule.
    •  45 CFR 164.524: The HIPAA privacy rule 45 CFR 164.524 permits a covered entity to charge an individual a reasonable, cost-based fee that will cover only particular limited labour, postage, and supply that may apply in offering an individual with a copy of patient healthcare information in the form and format requested or agreed to by the individual.
    • 45 CFR 164.524(b)(1): 45 CFR 164.524(b)(1) particularly deals with the HIPAA rules governing individual access to protected health information. This law establishes five main HIPAA standards that healthcare practitioners should implement within their organisations. These standards include; Access to protected health care information, request for access and timely action, provision of access; denial of access; and documentation.
    • 45 CFR § 164.502(g): Subject to certain exceptions, 45 CFR § 164.502(g) privacy rule requires that all covered entities treat a patient’s personal representative as the individual concerning the disclosure and use of the patient’s protected health information, as well as the individual’s right under the rule.

    Who Can Use Medical Authorization Letters?

    The overarching consequence of not using the release form is that the healthcare provider will not release the information requested. Some everyday situations that may call for the use of such forms include:

    Requesting for yourself

    Even though the medical records are yours, health providers may not authorise you to access or transfer your records without proper authorization. For you to be allowed to access or transfer your medical records, you must send a letter to the relevant authorities within 30 days. If not authorised to transfer or access the information, article 45 CFR 164.524 requires that a letter be sent to you explaining why such records have not been made accessible to you.

    Requesting for someone else

    There are other instances where one may be unable to request their own health information and have other people do it on their behalf. 45 CFR § 164.502(g) states that any person may obtain health records on behalf of someone else.

    People authorised to act on behalf of the patient may include:

    Personal representatives

    An individual granted power of attorney, an agent mentioned in the medical power of attorney, usually has the power to obtain the person’s personal information if they incapacitated or unavailable to share such information directly because the POA establishes that they are acting in the patient’s best interest.

    In other situations, the court may opt to appoint a guardian, caregiver, or any other person to obtain or release a person’s information. In such cases, such orders or decrees must be attached to the HIPAA form for them to be given access to the patient’s personal information.

    The second instance is when an adult or legal guardian is looking to access or transfer an individual’s health information. Under federal law, an adult or legal guardian is legally authorised to obtain a minor’s health information. However, the state law requires that if such records are to be used to offer the minor health care services, the minor must consent to such care-based services.

    Administrator of estate

    Another person that may be allowed to request someone else’s medical records is an administrator, executor, or any other authorised individual with authority to act on a deceased person’s estate. In the event that the medical records of a deceased person are required for whatever reason, the person appointed in the Last Will and Testament (if the person left one) or appointed by the court may be able to request/use or disclose such information as long as their actions are in the best interest of the deceased.

    How to Request Authorization

    Health information is usually very crucial and should be handled with utmost care. To be given access to health information, they should consider using an authorization form for medical records.

    Here is how to properly request authorization:

    Request the medical records

    Write a medical records release authorization letter to the relevant office requesting the release, access, or transfer of health information. It is essential to follow the state’s guidelines on how to craft the form to ensure that all essential elements are properly captured to avoid inconveniences.  

    Send the letter to the medical facility

    After drafting the authorization form and making sure that the information captured is correct, send the authorization form to the medical facility. It is recommended to send the letter early enough, usually, 30 days, to compile, document, release, or transfer such records.

    Receive the medical reports

    After sending the form, the medical facility will determine if the information transfer, release, or access is approved. If your request is not approved, the medical facility under article 45 CFR 164.524 is required to send a letter to you explaining why such records have not been made accessible to you.


    Before an individual, their representative, or agent can be allowed by a medical facility to access or transfer a person’s health information, the medical facility will require that a medical records release form be written and signed to protect its confidentiality. It is essential to understand that medical facilities operate within specific regulations; when requesting health information, whether yours or another person’s, make sure to follow all their guidelines regarding the same and write an authorization form to avoid any inconveniences.

    About This Article

    Maria Latimer
    Authored by:
    U.S. Licensed Attorney - Commercial Civil Litigation, Employment and Labor Law, Family Law, Intellectual Property Protection and Counseling
    Maria Latimer stands as a meticulously detail-oriented attorney, deeply entrenched in the multifaceted realms of the U.S. legal framework. With expertise spanning business formation and structures, she is adept at commercial civil litigation, navigating the intricacies of employment and labor law, and addressing delicate family matters, particularly in divorce and prenuptial contexts. Additionally, Maria's proficiency in intellectual property ensures robust protection and insightful counseling. Her portfolio is a testament to her versatility and depth, comprising a plethora of contracts she has crafted, ranging from Consulting and Operating Agreements to more nuanced documents like Non-solicitation and Confidentiality Agreements. From Website Privacy Policies to intricate Licensing and Financing Agreements, Maria's comprehensive expertise ensures that she remains a leading figure in the legal landscape, offering unparalleled expertise across her practice areas.

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