Free Release of Medical Records Forms (Authorization Process)

A Medical Record Release Form permits healthcare providers to share a patient’s health record. It gives the consent of the patient or a third party on behalf of the patient that their medical information may be shared with relevant parties.

Improvements in the field of medicine and health care are vital to optimal productivity and global harmony. Legislation on healthcare is essential to ensure that health workers provide the best care to patients while considering the requirements of these patients regarding their treatment.

To provide optimal care to a patient, the physician may sometimes have to share patient information with a third party, which requires the consent of the patient, obtained through this form. To safeguard patient information and confer authority on the right person, this form should contain all the information it needs to qualify as a legal document. All the essential elements that should be included in such a form have been discussed in this article.

Medical Release Forms and Templates

Free Medical Release Form Template

Editable Medical Release Form Sample

    What is a Medical Record Release Form?

    A medical release form is a legal document with which a patient permits their physician to share their health information with a third party. These include learning institutions, the patient’s employers, and family members. A patient may sign this  form for several reasons, such as seeking a job or college application, since medical history is a requirement in such places, or because another physician has the ability to offer more excellent healthcare or has more information about the medical condition.

    Alternative names 

    Several terms describe a form for accessing the medical records of a patient that allows a physician to share a patient’s information with a third party.

    These include:

    • Medical information release form
    • Medical records request
    •  Medication records authorization
    •  Request for medical records


    Providing adequate healthcare while abiding by a patient’s wishes concerning health and welfare may become challenging. Therefore, you will need proper regulations and laws to guide your decisions while also conforming to your patient’s wishes. Thus, the medical information release form permits you to share patient information with a third party without breaching patient-doctor confidentiality.

    Involved Parties in Record Release Form

    Depending on the circumstances surrounding the issuance of this document, four parties are usually required in a medical release form.

    These include:


    The patient is the individual who has received or is receiving medical care and for whom the medical release form is requested. Therefore, this party is most important in issuing this document as treatment and medical care information directly concern them.


    The guardian is a representative of the will of the patient when they are minors or incapable of making sound decisions concerning their healthcare. As a result, in certain situations, this party has the authority to make decisions regarding the medical release form.

    The organization that holds the record

    This is any medical facility where the patient is being treated and has information about the medical records of the patient. This includes the therapist’s office, hospital, clinic, acupuncturists, etc.

    Organization or individual who requires information

    Depending on the circumstances, the recipient of the medical information can be an organization or an individual. The physician may need to share your medical information with lawyers in the case of lawsuits or schools, your place of employment, insurance companies, and other physicians when referring you to a specialist.

    How to Obtain It?

    The medical record release form is a legal document under the Health Insurance Portability and Accountability Act (HIPAA), requiring 45 CFR Part 160 and 45 CFR Part 164. Therefore, this document is a legal document, and thus, requests for this document must follow a systematic procedure that requires the following steps:

    Request for the patient’s medical files

    The organization or individual who has the medical records (the medical personnel) may ask the requesting party to send their request in writing and include important information in their request form, such as

    Name of healthcare provider and the receiving party

    Both the person submitting the medical release form and the party receiving it must be mentioned in the request.


    This is the date until which the medical release form will remain valid. It will be invalid after this date, and the individual or organization with the patient’s medical records is not obliged to acknowledge this request.

    Type of medical record

    This includes asking for a specific health record or the patient’s complete health record.

    Date of expiration

    The date when the medical records expire as a legal document should be mentioned.

    Method of sending the medical form

    The requesting party should specify the method for sending their medical forms, including CDs, USBs, Flash Drive electronic documents, or by mail.

    Note: If the requester does not receive feedback on the records within 5-7 working days after they have requested them, they should call the medical facility to follow up. The medical facility often has 30 days to release the requested records and an additional 30 days in case of delays in the release of medical forms.

    State Laws and Fees

    Fees and billing for medical record request forms vary between medical offices. Only large medical organizations require payments and fees to copy and send medical records to recipients. However, the various states give a maximum limit to charges on medical request forms. Below is a list of maximum fee laws of various states:

    States and their maximum fee lawsStates and their maximum fee laws
    Alabama (§ 12-21-6.1)Nebraska (§ 71-8404)
    Arizona (§ 12-2295)Nevada (§ 629.061)
    Arkansas (§ 16-46-106)New Hampshire (§ 332-I)
    California (EVID Code § 1158(2) and § 1563(6))New Jersey  (§ 8:43G-15.3§ 13:35-6.5)
    Colorado (6CCR 1011-1 Chapter 2 Part Mexico  (§
    Connecticut (§ 19a-490b)New York (Title 2: Section 17)
    Delaware (Title 24: Chapter 1700, Section 29)North Carolina (§ 90-411)
    Florida (§ 395.3025 (1))North Dakota (§ 23-12-14)
    Georgia (§ 31-33-3)Ohio (§ 3701.742)
    Hawaii (§ 622-57(g))Oklahoma (§ 76-19)
    Illinois (735 ILCS 5/8-2005)Oregon (OAR 847-012-0000)
    Indiana (760 IAC 1-71-3(a))Pennsylvania (48 Pa.B. 7712)
    Iowa (§ 622.10)Rhode Island (R5-37- MD/DO Section 11.2)
    Kentucky (§ 422.317)South Carolina (§ 44-115-80)
    Louisiana (§ 1165.1)South Dakota (§ 36-2-16)
    Maine (§ 1711-A)Tennessee (§ 63-2-102)
    Maryland (§ 4-304)Texas (§241.154)
    Massachusetts (Title XVI, Ch III, Section 70)Utah (78B-5-618)
    Michigan (Public Act 47 of 2004. MCL 333.26269)Vermont (§ 9419)
    Minnesota (§ 144.292)Virginia (§ 8.01-413)
    Mississippi (§ 11-1-52)Washington (WAC 246-08-400)
    Missouri (§ 191.227.5)West Virginia (§ 16-29-2)
    Montana (§ 50-16-540)Wisconsin (§ 146.83 (3f)(c)2)

    What does the Medical Release Form Include?

    This form is a legal document and thus has a certain format that should be followed, including the following:

    Patient’s information

    The patient’s information is also the patient’s identifier, which helps the reader ensure that they have the correct person’s records. Therefore, it must contain clear and precise patient information, including name, age, social security number, and email address. There will also be times when a parent will release the medical form on behalf of their child.

    The recipient’s information

    The patient must clearly state the names of those who can access their records. Never share patient information with anyone unless explicitly mentioned on the form. Create form fields for those who are authorized to view the information, such as name, contact information, email address, and place of business. 

    Information to be shared

    The patient must list what information they should share. The patient may choose what information on tests, scans, results, images, and notes to share and state the conditions, if any.

    Purpose of authorization

    The patient should clearly state the reason for releasing their medical records to prevent misinterpretation and the wrong dispersal of their information. Some reasons may include insurance claims, medical disability claims, worker’s compensation claims, college immunization notification, and specialist consultation, among others.

    Due date of authorization

    This field allows the patient to restrict the period of validity of the medical release form. It is wise to add a footnote that the release forms expire after ninety days if there is no time limit. This is standard practice. 


    This clarifies to the patient how the release form functions as well as its benefits and drawbacks. In addition, this clarity safeguards the healthcare provider from any legal case based on a misunderstanding on the part of the patient.

    Date and signatures of respective parties

    End the release form with a field for date and signature, which the patient can sign as proof of consent.

    Tip: You should note that the patient must be physically sound and mentally stable with cognitive reasoning abilities when signing the medical release form. A sick or unstable patient’s consent is invalid, and medical personnel cannot receive or act upon a release form from a patient in this state. In addition, a physician or medical personnel who acts on the medical release form from a patient in an unstable mental state will be responsible for wrongly releasing the patient’s data. Therefore, it is safer for medical personnel to request that the patient’s spouse or legal guardian sign the medical release form when they are unsure of their mental state.

    The patient’s parents or legal guardian should sign a statement that mentions that their ward is a minor and the patient’s exact age. This is because the law does not permit patients to sign the medical release form in most states.

    By US States

    Types of Medical Record Release Form

    The following are three main types of this form:

    Free Sample Chiropractic HIPPA

    Printable Dental HIPPA Example

    Editable Medicare HIPPA Word

      Who May Obtain the Form?

      The medical release form gives the requesting party access to confidential patient information, so only authorized people should access such files. These include:

      Personal representatives

      This person is also an agent or attorney and has the legal right to obtain a patient’s medical record. This person obtains their authority from a court, where they receive power to serve as legal caregivers for the patient. The court must adjoin this decree to a HIPAA decree form.

      A minor cannot make healthcare decisions, and therefore their legal guardian or parent makes them on their behalf. However, in some states, the caregiver or physician must also obtain consent from the child.

      The administrator of the estate

      This is anyone with authority over a person’s estate or affairs after their death. The administrator may require a record of the deceased’s health, and so may have to access their medical records.

      Tip: These parties are only privy to the medical records for a specified time interval. There is usually an expiration date when creating this form, which invalidates the third party’s authority over the patient’s health record. While a medical records release form can remain valid for several years, it is prudent to set an expiration date of about two years or less to limit the third party’s access to patient medical records.


      The medical record release forms allow access to a patient’s private files. As such, you must take care that this form covers all necessary information for a legal document, as well as protecting your interests and those of your patient. A medical request form serves as a legal witness that absolves the medical personnel from charges of indiscriminate sharing of confidential patient medical records while allowing the patient to decide which parties should have access to their medical history.

      This form might not be accepted as legal documentation in court if it lacks all the necessary information. So, the guidelines discussed above will help ensure that the form for the release of medical records is properly drafted and does not exclude any important information. 

      About This Article

      Melissa Horton
      Authored by:
      Legal Writing | M.A Marketing, B.A. Finance
      Melissa Horton is a highly skilled legal writer and co-owner of a leading financial planning firm in Washington, D.C. With over a decade of experience in the financial services and planning industry, Melissa's expertise lies in teaching clients how to maintain sustainable financial health. She holds a JD degree and possesses a deep understanding of legal principles and regulations, enabling her to deliver exceptional legal writing that is both informative and accessible. Melissa's passion for helping individuals navigate complex legal matters shines through in her work, making her a trusted authority in the field of legal writing.

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