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Medical Records Release Authorization Form (Waiver) | HIPAA

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Medical Records Release Authorization Form (Waiver) | HIPAA

Updated June 13, 2024

The medical record information release (HIPAA) form allows patients to give authorization to a 3rd party and access their health records. It also allows the added option for healthcare providers to share information.

Powers granted under a medical release can be revoked or reassigned at any time.

Laws45 C.F.R. Part 160 and 45 C.F.R. Part 164

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

Table of Contents

By State

By Type (4)


Standard HIPAA Release Form

Download: PDF

 

 

 


Chiropractic HIPAA Form

Download: PDF

 

 

 


Dental (ADA) HIPAA Form

Download: PDF

 

 

 


Medicare HIPAA (Form CMS-10106)

Download: PDF

 

 

 

How to Get Medical Records (3 steps)

  1. Request the Medical Records
  2. Send the Letter
  3. Receive the Medical Records

Accessing and obtaining your medical records is a requirement under 45 CFR 164.524 which requires that any request made to access or transfer medical records must be completed within 30 days, or a letter must be sent to the requestor stating why the records are delayed.

1. Request the Medical Records

person writing official request for medical records

To legally request medical records, under 45 CFR 164.524(b)(1), the entity holding the records may require that the request is made in writing. Therefore, use the Standard Form and use the “How to Write” section of this page to enter the specific fields required to complete.

The 4 sections are:

  • Releasor and Recipient – Who has the medical records, and to who will they be sending them?
  • Time Period – What dates are authorized for release?
  • Record Types – Should only specific records be released about certain medical conditions, or should all the patient’s records be released?
  • Expiration Date – Usually, a date is listed at which it expires for legal purposes.

2. Send the Letter

person filling out envelope at post office

When sending the letter to the medical facility it is best to request how the record should be sent; examples include, an electronic document (PDF, Word), USB Flash Drive, CD, etc. The medical facility may charge a fee for sending the records, although, they are prohibited from charging for processing the request.

3. Receive the Medical Records

person checking mailbox

Modern medical facilities are typically aware that time is of the essence in regards to the records of an individual. Therefore, if the requested information is not received within 5 to 7 business days the requestor should call or ask to know the status of the transfer.

The medical facility has 30 days to release the requested medical records. If the initial 30-day period is not met they may extend for an additional 30 days only if they send a letter to the requestor stating why the transfer is delayed. Only one (1) extension period is allowed by law.

Getting for Someone Else (3 options)

Under 45 CFR § 164.502(g), an individual may obtain medical records on behalf of someone else.

  1. Personal Representative
  2. Adult or Legal Guardian
  3. Administrator of an Estate

1. Personal Representative

patient in hospital bed in conversation with personal representative and another individual

An individual, such as an attorney-in-fact (or “agent”) mentioned in a Medical Power of Attorney, commonly has powers to obtain medical records. In addition, for any person that has been appointed by a court to act as a caregiver or guardian, the judgment, order, or decree must be attached to the HIPAA release form.

2. Adult or Legal Guardian

couple sitting with young child

An adult or legal guardian is legally authorized, under federal law, to obtain the medical records of a minor. If the medical records are for healthcare services that will be provided, the minor may be required to consent to such care based on State law.

3. Administrator of an Estate

judge in courtroom holding gavel

An administrator, personal representative, executor, or another authorized person with the authority to act on the deceased person’s estate. Suppose, for any reason, the medical records of the deceased are requested. In that case, the administrator appointed in the Last Will and Testament or a court-appointed authority may be able to obtain the records.

Is There a Fee ($) to Release Medical Records?

Yes, but this depends on the medical office and the state it is located. Generally speaking, smaller offices do not require a fee for copying and transferring medical records. If a medical office does charge a fee, it cannot be more than the statutory limit (see table below):

State-by-State Maximum Limits ($)

State Maximum Fees ($) Laws
Alabama Search Fee: $5

Pages 1-25: $1/page

Pages 26+: $0.50

Other Documents: Actual cost of reproduction.

§ 12-21-6.1
Alaska N/A No Statute
Arizona Reasonable Fee § 12-2295
Arkansas Search Fee: $15

Pages 1-25: $0.50/page

Pages 26+: $0.25/page

§ 16-46-106
California Search Fee: $4

Evidence Fee: $15

Pages 1+: $0.10/page

Microfilm: $0.20/page

EVID Code § 1158(2) & § 1563(6)
Colorado Search Fee: $18.53 flat fee (First ten pages)

Pages 11 – 40: $0.85 per page

Pages 41+: $0.57 per page

Microfilm: $1.50 per page

6CCR 1011-1 Chapter 2 Part 5.2.3.4
Connecticut Pages 1+: $0.65 per page § 19a-490b
Delaware Pages 1 – 10: $2.00 per page

Pages 11 – 20: $1.00 per page

Pages 21 – 60: $0.90 per page

Pages 61+: $0.50 per page

Microfilm: Actual cost of reproduction.

Title 24: Chapter 1700, Section 29
Florida Search Fee: $1.00 (Per year per request)

Pages 1+: $1.00 per page

Microfilm: $2.00 per page

§ 395.3025 (1)
Georgia Search Fee: $25.88

Pages 1 – 20: $0.97 per page

Pages 21 – 100: $ 0.83 per page

Pages 101+: $0.66 per page

Certification Fee: $9.70

§ 31-33-3
Hawaii Reasonable Fee § 622-57(g)
Idaho N/A No Statute
Illinois Search Fee: $29.09

Pages 1 – 25: $1.09 per page

Pages 26 – 50: $0.73 per page

Pages 50+: $0.36 per page

Microfilm: $1.82 per page

735 ILCS 5/8-2005
Indiana Search Fee: $20.00 (includes first 10 pages)

Pages 11 – 50: $0.50 per page

Pages 51+: $0.25 per page

Affidavit/Certification: $20.00

760 IAC 1-71-3(a)
Iowa Reasonable Fee § 622.10
Kansas Reasonable Fee REPEALED
Kentucky First (1st) Copy: Free

Second (2nd) Copy: $1.00 per page

§ 422.317
Louisiana Search Fee: $25.00

Pages 1 – 25: $1.00 per page

Pages 26 – 350: $0.50 per page

Pages 351+: $0.25 per page

Max Fee for Electronic Records: $100.00 per request

§ 1165.1
Maine Search Fee: $5.00 (Includes first page)

Pages 2+: $0.45 per page

Max Fee: $250.00

Max Fee for Electronic Records: $150.00 per request

§ 1711-A
Maryland Search Fee: $22.88

Pages 1+: $0.83 per page

Electronic Records Search Fee: $22.88

Electronic Records Pages 1+: $0.62 per page

Max Fee for Electronic Records: $81.63 per request

§ 4-304
Massachusetts Search Fee: $25.01

Pages 1 – 100: $0.84 per page

Pages 100+: $0.43 per page

Social Security: No charge for a request to support a claim under the social security act.

Title XVI, Ch III, Section 70
Michigan Search Fee: $25.38

Pages 1 – 20: $1.27 per page

Pages 21 – 50: $0.63 per page

Pages 51+: $0.25 per page

Public Act 47 of 2004. MCL 333.26269
Minnesota Search Fee: $19.19

Pages 1+: $1.44 per page

X-rays: $10 Search Fee plus the actual cost of reproduction.

§ 144.292
Mississippi Search Fee: $20.00 Flat Fee (first 20 pages)

Pages 21 – 100: $1.00 per page

Pages 101+: $0.50 per page

Search/Storage Fee: $15.00 (Only charged if records are retrieved from off-site location)

Certification Fee: $25.00

§ 11-1-52
Missouri Search Fee: $26.06

Pages 1+: $0.60 per page

Storage Fee: $24.40 (Additional fee if records are retrieved off-site)

Max Fee for Electronic Records: $114.17

§ 191.227.5
Montana Search Fee: $15.00

Pages 1+: $0.50 per page

§ 50-16-540
Nebraska Search Fee: $20.00

Pages: 1+: $0.50 per page

X-rays: Actual cost of reproduction.

§ 71-8404
Nevada Pages 1+: $0.60 per page

X-rays: Reasonable Fee

§ 629.061
New Hampshire Whichever is greater: $15 for first 30 pages or $0.50 per page
X-rays: Reasonable Fee
§ 332-I
New Jersey Search Fee: $10.00

Pages 1 – 100: $1.00 per page

Pages 101+: $0.25 per page

Max Fee: $200.00

§ 8:43G-15.3§ 13:35-6.5
New Mexico Pages 1 – 15: $30.00 flat fee

Pages 16+: $0.25 per page

X-rays: Actual cost of reproduction.

§ 16.10.17.8
New York Pages 1+: $0.75 per page

X-rays: Actual cost of reproduction.

Title 2: Section 17
North Carolina Pages 1 – 25: $0.75 per page

Pages 26 – 100: $0.50 per page

Pages 100+: $0.25 per page

Minimum Fee: $10.00

§ 90-411
North Dakota Search Fee: $20.00 (Includes pages 1-25)

Pages 26+: $0.75 per page

Electronic Records Search Fee: $30.00 (Includes pages 1-25)

Electronic Records Pages 26+: $0.25 per page

§ 23-12-14
Ohio Search Fee: $20.42

Pages 1 – 10: $1.34 per page

Pages 11 – 50: $0.69 per page

Pages 51+: $0.27 per page

X-rays: Search Fee plus $2.27 per page

§ 3701.742
Oklahoma Search Fee: $10.00

Pages 1+: $0.30 per page

X-rays: $5.00 per page

Max Fee: $200.00

§ 76-19
Oregon Search Fee: $30.00 (Includes pages 1-10)

Pages 11-50: $0.50 per page

Pages 51+: $0.25 per page

X-rays: Actual cost of reproduction.

OAR 847-012-0000
Pennsylvania Search Fee: $23.45

Pages 1 – 20: $1.58 per page

Pages 21 – 60: $1.17 per page

Pages 61+: $0.40 per page

Microfilm:  $23.45 + $2.33 per page

48 Pa.B. 7712
Rhode Island Pages 1 – 10: $2.50 per page

Pages 10 – 50: $0.75 per page

Pages 51+: $0.50 per page

R5-37- MD/DO Section 11.2
South Carolina Search Fee: $26.67

Pages 1 – 30: $0.69 per page

Pages 31+: $0.53 per page

Max Fee for Electronic Records: $160.05

§ 44-115-80
South Dakota No Current Fee Schedule § 36-2-16
Tennessee Search Fee: $18.00 (Includes pages 1 – 5)

Pages 6 – 50: $0.85 per page

Pages 51 – 250: $0.60 per page

Pages 251+: $0.35 per page

§ 63-2-102
Texas Search Fee: $48.77 (Includes pages 1 – 10)

Pages 11 – 60: $1.64 per page

Pages 61 – 400: $0.80 per page

Pages 401+: $0.44 per page

§241.154
Utah Search Fee: $21.16

Pages 1 – 40: $0.53 per page

Pages 41+: $0.32 per page

78B-5-618
Vermont Whichever is greater: $5 or $0.50 per page

Social Security: No charge for a request to support a claim under the social security act.

§ 9419
Virginia Search Fee: $20.00

Pages 1 – 50: $0.50 per page

Pages 51+: $0.25 per page

Max Fee: $150.00

Electronic Records Search Fee: $20.00

Electronic Records Pages 1 – 50: $0.37 per page

Electronic Records Pages 51+: $0.18 per page

Electronic Records Max Fee: $150.00

Microfilm Search Fee: $20.00

Microfilm Pages 1+: $1.00 per page

§ 8.01-413
Washington Search Fee: $26.00

Pages 1 – 30: $1.17 per page

Pages 31+: $0.88 per page

WAC 246-08-400
West Virginia Search Fee : $20.00

Pages 1+ : $0.40 per page

Pages 1+ Electronic Records: $0.20 per page

Max Fee Electronic Records: $150

§ 16-29-2
Wisconsin Search Fee: $22.61

Pages 1 – 25: $1.14 per page

Pages 26 – 50: $0.86 per page

Pages 51 – 100: $0.56 per page

Pages 101+ $0.34 per page

Microfilm and other media: $22.19 + $1.68 per page

X-rays : $22.19 + $11.28 per series

Certification (if not patient or their representative): $9.04 per request

§ 146.83 (3f)(c)2
Wyoming N/A No Statute

 

Sample

Download: PDF, MS Word, OpenDocument

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Date: [DATE]

I. THE PATIENT. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Patient’s Name: [PATIENT’S NAME]
Date of Birth:  [DATE OF BIRTH]
Social Security Number: [SSN]

II. AUTHORIZATION. I authorize [AUTHORIZED PARTY’S NAME] (“Authorized Party”) to use or disclose the following: (check one)

☐ – All of my medical-related information.
☐ – My medical information ONLY related to: [ENTER MEDICAL CONDITION]
☐ – My medical-related information from [DATE] to [DATE].
☐ – Other: [OTHER]

Hereinafter known as the “Medical Records.”

III. DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records to: (check one)

☐ – Any party that is approved by the Authorized Party.

☐ – ONLY the following party:

Name: [RECIPIENT’S NAME]
Address: [ADDRESS]
Phone: [PHONE] Fax: [FAX]
E-Mail: [E-MAIL]

IV. PURPOSE. The reason for this authorization is: (check one)

☐ – General Purpose. At my request (general).

☐ – To Receive Payment. To allow the Authorized Party to communicate with me for marketing purposes when they receive payment from a third party.

☐ – To Sell Medical Records. To allow the Authorized Party to sell my Medical Records. I understand that the Authorized Party will receive compensation for the disclosure of my Medical Records and will stop any future sales if I revoke this authorization.

☐ – Other: [OTHER]

V. TERMINATION. This authorization will terminate: (check one)

☐ – Upon sending a written revocation to the Authorization Party.
☐ – On the following date: [DATE]
☐ – Other: [OTHER]

VI. ACKNOWLEDGMENT OF RIGHTS.

I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create Medical Records for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Signature of Patient: __________________________ Date: ________________
Print Name: ________________________

(IF THE PATIENT IS UNABLE TO SIGN, USE THE SIGNATURE AREA BELOW)

The patient is unable to sign due to: (check one)

☐ – Being a Minor. Patient is [#] years old and a minor under state law.
☐ – Being Incapacitated. Patient is incapacitated due to: [DESCRIBE CONDITION]
☐ – Other: [OTHER]

 

Signature of Representative: __________________________ Date: ________________
Print Name: ________________________

Relationship to Patient: ☐ Parent ☐ Spouse ☐ Guardian ☐ Other: [OTHER]

ADDITIONAL CONSENT FOR CERTAIN CONDITIONS

I. SENSITIVE INFORMATION. This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.

(check one)

☐ – I consent to have the above information released.

☐ – I do not consent to have the above information released.

 

Signature of Patient: __________________________ Date: __________________
Print Name: ________________________

 

II. HIV/AIDS. This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.

(check one)

☐ – I consent to have the above information released.

☐ – I do not consent to have the above information released.

 

Signature of Patient: __________________________ Date: __________________
Print Name: ________________________

Related Forms


Minor (Child) Medical Consent – To elect someone else to have medical decision-making responsibilities for a minor child.

Download: PDF, MS Word, OpenDocument

 

 


Minor (Child) Power of Attorney – Also known as a ‘consent’ form that authorizes a family member, friend, or guardian to have the responsibility to make education, medical, and everyday living decisions.

Download: PDF, MS Word, OpenDocument

 

 


Medical Power of Attorney – May be used by anyone to give someone else the responsibility of handling their medical needs only if the patient is not able to speak for themselves.

Download: PDF, MS Word, OpenDocument

 

 


Parental Consent for a Minor’s Abortion – To be used in States that require the consent of a parent or guardian for an individual under eighteen (18) years of age to receive an abortion.

Download: PDF