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Medical Record Release Form Template

Simplify Your Medical Record Request Process

Struggling to manage patient access to medical records? This medical record release form template is designed for healthcare professionals and patients alike, ensuring a smooth process for requesting records. With clear guidance, you can easily obtain necessary health documentation, maintain compliance, and protect patient privacy, all while streamlining your operations. Experience the ease of creating and managing records with our user-friendly template, available for you to explore instantly.

Use this Template (FREE) Live Preview
Patient full legal name
Date of birth
Patient phone number
Patient email address
Patient mailing address
Are you the patient?
Yes
No
If you are not the patient, enter your full name
If other or required, describe your authority to act for the patient
Your relationship to the patient
Parent/guardian
Legal guardian
Health care power of attorney/agent
Spouse/partner
Adult child
Other
Please Specify:
Provider or facility name authorized to disclose records
Provider phone
Provider fax
Provider address
Organization or person to receive the records
Attention to (department or individual)
Recipient email
Recipient phone
Recipient fax
Recipient mailing address
Preferred delivery method
Secure email
Fax
Mail
In-person pickup
Patient portal upload
Preferred record format
Electronic PDF
Paper copies
CD/DVD for images
Not specified
Select the records to be released
Describe specific records, dates of service, body part, or other details
Date range start (if applicable)
Date range end (if applicable)
Purpose of disclosure
Continuity of care/treatment
Personal use
Insurance
Legal
Employment
School
Disability/Workers compensation
Other
Please Specify:
Include HIV/AIDS-related information?
Yes
No
Include mental health records or psychotherapy notes?
Yes
No
Include substance use disorder treatment records?
Yes
No
Include genetic testing information?
Yes
No
Include reproductive/sexual health or STI information?
Yes
No
I understand email or fax may not be fully secure and authorize transmission using the selected method.
Yes
No
I understand I may revoke this authorization in writing at any time.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand treatment, payment, enrollment, or eligibility is not conditioned on signing this authorization.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand records disclosed may be re-disclosed by the recipient and may no longer be protected.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Authorization expiration date
I authorize the release of the records as described above.
Yes
No
Signature of patient or authorized representative (type full legal name)
Date of signature
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paper art illustration for medical record release form template and FormCreatorAI article

When to use this form

Use this authorization when you need to share health information with another party. It helps you, your caregiver, or your care team send the right records quickly and securely. Common scenarios: you are moving care to a new facility and must send charts and imaging (see Hospital transfer form); you need copies for a second opinion or insurance; you are the executor seeking a parents records (see Deceased parent medical record request form); or you want a provider to send your own files (start with the Medical record request form). The result: fewer delays, clear consent, and a documented trail of who gets what and when.

Must Ask Medical Record Release Questions

  1. Whose records should we release?

    Full name, date of birth, and any medical record number prevent mix-ups and speed verification. If you are not the patient, state your role (for example, parent, guardian, executor) and include proof of authority.

  2. Which records and date range do you authorize us to share?

    Specifying types (notes, labs, imaging) and dates limits oversharing and protects privacy. It also tells staff exactly where to look, which shortens turnaround time.

  3. Who is authorized to receive the records, and how should we deliver them?

    Naming the person or organization with contact details prevents misdelivery. Choosing a method (secure portal, encrypted email, mail, fax, pickup) balances speed and security.

  4. Do you allow release of sensitive information (HIV/STI, mental health, genetic, substance use)?

    Many jurisdictions require explicit consent for these categories. Clear consent avoids legal delays and ensures the recipient gets only what you intend.

  5. When should this authorization expire?

    An end date or event (for example, after surgery) reduces the risk of future unintended disclosures. It keeps your consent time-bound and easier to audit.

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