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Hospital Patient Release Form Template

Streamline Your Patient Release Process with Ease

Obtaining your release from the hospital can be a complex process, but having a clear, concise form can simplify it significantly. This Hospital Patient Release Form Template is designed to help healthcare facilities get consent from patients or their guardians effectively. It supports a smooth discharge process, ensures you comply with healthcare regulations, can be customized to fit various medical scenarios, and is a user-friendly solution that saves your staff time. Explore this live template to streamline the release process effortlessly.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Medical record number (MRN)
Primary phone number
Discharge date
Attending physician
Reason for hospitalization (brief summary)
Discharge disposition
Home without services
Home with home health services
Rehabilitation facility
Skilled nursing facility
Transfer to another hospital
Against medical advice
Other/Not listed
Condition at discharge
Improved
Stable
Unchanged
Worsened
Not applicable
Mobility status at discharge
Independent
Uses cane
Uses walker
Uses wheelchair
Requires assistance
Bedbound
Not applicable
Assistance or services needed after discharge
Please Specify:
Instruction topics reviewed with patient/caregiver
Medications and dosing
Activity and mobility
Diet and nutrition
Wound or device care
Symptoms to watch and when to seek care
Follow-up plan and appointments
Restrictions and precautions
Who to contact with questions
Other
Please Specify:
Patient/caregiver understanding confirmed
Yes
No
Interpreter used during teaching
Yes
No
List new or changed medications (name, dose, frequency)
New or changed medications prescribed
Yes
No
Follow-up date
Follow-up appointment scheduled
Yes
No
All personal belongings returned to patient
Yes
No
Name of person accompanying patient (if applicable)
Discharge transportation
Self
Family or friend
Ride service
Ambulance or medical transport
Public transportation
Other
Please Specify:
I received and understand the discharge instructions and had an opportunity to ask questions
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
Name of authorized caregiver/recipient (for discharge summary)
Authorize the hospital to share my discharge summary with the caregiver named below
Yes
No
Patient or legal guardian signature
Name of signer
Date signed
Staff witness name
Staff witness signature
Relationship to patient
Self
Parent
Legal guardian
Durable power of attorney
Spouse/Partner
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Medical record number (MRN)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a hospital patient release form with medical symbols and design elements

When to use this form

Use this form when a patient is medically cleared to leave and needs to authorize release, document aftercare, and name who will pick them up. It is helpful for adults leaving inpatient care, same-day surgery, or observation, and for caregivers coordinating a safe ride home or transfer to another facility. Employers benefit when you include return-to-work notes and any limits. Clinicians use it to record consent and reduce delays. If you also need detailed discharge instructions, pair this with the Hospital discharge form. For jobs or placements that require screening, you can attach proof from a TB Skin test results form to support clearance.

Must Ask Hospital Patient Release Questions

  1. Who is the patient, and who is authorized to receive them at discharge?

    This confirms identity and names a responsible adult or facility to accept the patient. Clear authorization prevents delays and keeps the handoff safe.

  2. What is the requested release date and time, and what is the destination?

    Scheduling details help staff arrange transport, teaching, and medications before you leave. Recording the destination ensures continuity if issues arise.

  3. What follow-up appointments, activity limits, and medication instructions apply?

    These details guide recovery and reduce readmission risk. Patients leave with one clear plan they can follow.

  4. Do you authorize sharing specific medical information with your employer or next provider?

    Stating what can be released speeds coordination and return-to-work decisions. If screening is required, attach results using the Urine drug screen form.

  5. Has the patient acknowledged the risks of leaving and received contact numbers for help?

    A signed acknowledgment protects you and the provider by documenting informed consent. It also tells the patient whom to call if symptoms worsen.

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