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Medical Records Release Authorization Form | HIPAA

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The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file. This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. If anyone would ask for medical information regarding a specific patient and their name is not listed on the HIPAA form, they would not be privy, by law, to any of the patient’s information under any circumstances. The document also provides the ability for healthcare providers to share information with each other. This document may be revoked and/or reassigned at the discretion of the patient 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

HIPAA Forms By State

Table of Contents

HIPAA Forms – By Type

How to Get 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.

Step 1 – Request the Medical Records

In order to legally request medical records, in accordance with 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 in order to enter the specific fields required to complete.

The 4 sections are:

  • Releasor and Recipient – Who has the medical records and who will they be sending them to?
  • TimePeriod – 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.

Step 2 – Sending the Letter

When sending the letter to the medical facility it is best to request how the record should be sent, examples include, 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.

Step 3 – Receiving the Medical Records

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 Medical Records for Someone Else

Under 45 CFR § 164.502(g), an individual may obtain medical records on behalf of someone else. There are three (3) options:

Option 1 – Personal Representative

An individual such as an attorney-in-fact (or “agent”) mentioned in a Medical Power of Attorney (also known as an “Advance Directive”) that is commonly signed with witnesses or a notary public in accordance with State law. This authorized representative of the patient will have the legal authority to obtain the records as long as the power of attorney document is attached to any request. In addition, if there is any person that has been appointed by the court to act as a caregiver or guardian for an individual, the judgment, order, or decree must be attached to to the release form.

Option 2 – Adult or Legal Guardian

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.

Option 3 – Administrator of an Estate

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

How to Write

DownloadAdobe PDF, Microsoft Word (.docx) or Open Document Text (.odt)

1 – Download The Authorization Template To Your Machine

The buttons on this page will each connect to the consent form imaged in the preview above. You can obtain this paperwork in any of the formats indicated under the image.

2 – Produce The Patient Information Requested In The Introduction

The full name of the Patient, as it appears on his or her I.D. cards, must be presented on the blank space labeled “Print Name Of Patient.”

In most cases, additional information will be needed to fully identify the Patient. Present his or her birth date on the “Date of Birth” line along with his or her social security number on the blank space labeled “SSN.”

3 – Document Who May Receive Information

Locate the area titled “I. Authorization.” Use the first blank line in this section to name the individual (Disclosing Party) who will be authorized to release the Patient’s medical records through this paperwork and the Health Insurance Portability And Accountability Act Of 1996. Make sure this Disclosing Party’s name is reported exactly as it appears on his or her identification papers (i.e. Driver’s License).

4 – Report The Type Of Information Your Agent May Receive, Use, And Dispense

Now that we have named the entity requiring the Patient’s consent, we will need to define what information the Patient is comfortable sharing. A short list of checkbox statements has been included to aid in this definition.

If the Patient would like all his or her medical information dispensed by the Disclosing Party named above, then mark the first checkbox. If the Patient only wishes for information pertinent to a specific subject be released by the Disclosing Party, then mark the second checkbox and report the nature of the information that can be released on the blank line after the words “…Relating To The Treatment Or Condition.” If the Patient would only like the medical records generated for his or her health care during a specific period of time to be released, then mark the third checkbox. Naturally, you will need to report a start date for this period and an end date. Use the two blank lines to record these dates in that order. If the Disclosing Party should only use the Patient’s medical records according to a different set of criteria from the options above then, mark the fourth checkbox then use the blank line labeled “Other” to give a full description of what the agent may and/or may not access. Locate the bold statement beginning with the phrase “The Above Party May Disclose…” then list the legal name of the entity the Patient authorizes his or her medical records released to. In addition to this entity’s name, you must enter its “Address,” “City,” “State,” “Zip,” “Phone,” “Fax,” and “Email” on the appropriately labeled blank lines. If more entities must be listed here, then you can use the software you are entering information with to paste more lines directly below this area. If you are filling this form out by hand, then make sure to cite a properly titled attachment (that is dated and signed) containing the entities authorized to receive the Patient’s medical information.

5 – Discuss The Purpose Of This Authorization

The next bold statement (“The Purpose Of This Authorization Is”) will be followed by a list of statements (each accompanied with a checkbox). Check the box that applies to the catalyst or reason the Patient’s medical records should be released.

If the Patient’s records should be released upon the request of the Patient, then mark the first checkbox. If there is a specific catalyst that will open the Patient’s records, then check the second box (“Other”) and describe this reason on the blank space provided. If the Disclosing Party should be able to contact the Patient for marketing purposes then mark the third box. If the Disclosing Party should be able to release the Patient’s health information to a third party for payment, then mark the last checkbox in this list. Next, the Patient should determine and report when the Disclosing Party’s right to share his or her medical records should end. If the Patient wishes this authorization to end on a specific date, then mark the first checkbox and enter this calendar date on the blank line presented after the words “On (Date).” The Patient can also set a specific event to terminate access to the Patient’s medical records by marking the second box and defining the catalyst event on the blank line after the words “…Following Event Occurs.”

6 – A Valid Authorization Signature From The Patient Must Be Present

The Patient should only sign this document after he or she has reviewed this entire document including the section titled “II. Rights.” Once this is done, the Patient must sign the blank line labeled “Signature Of Patient.” In addition to his or her signature, the Patient must document the current date on the line he or she has just signed. This will act as this paperwork’s signature date.

This paperwork requires the signature of a competent adult in his or her right mind. This means that if the Patient is a child/minor or lacks the ability to represent himself or herself, a legal representative of the Patient must sign this document as well. First, locate the bold underline statement starting with the words “If The Patient Is A…” then mark one of the boxes below it to describe the Patient’s situation.

If he or she is a child/minor, you must mark the first checkbox and record the child’s age on the blank line for this choice.

If the Patient is an adult but cannot sign this document (i.e. he or she is in a permanent vegetative state), then mark the second checkbox and state the reason in the space provided.     Once the reason why the Patient cannot personally provide an acceptable signature has been explained, the Patient’s Representative must sign the blank line labeled “Signature Of Authorized Representative.” He or she must also enter the date of this signature on the next blank line and print his or her name on the line labeled “Print Name Of Authorized Representative.” Finally, the Authorized Representative must mark the checkbox labeled “Parent,” “Legal Guardian,” “Court Order,” or “Other” to indicate his or her status. If the checkbox labeled “Other” is marked, then a specific reason as to how he or she can legally sign this document on behalf of the Patient must be given (i.e. the Patient has been deployed by the military and left such actions to an agent).

7 – Additional Sensitive Items May Be Authorized At The Patients Discretion

In the section titled “III. Additional Consent For Certain Conditions,” the Patient will have the opportunity to definitively consent or object to any medical records containing information regarding physical or sexual abuse, drug abuse, alcoholism, sexually transmitted diseases, abortions, or mental health treatment being released by the Disclosing Party. If the Patient is comfortable with the Disclosing Party giving such information, then mark the first checkbox. If not, then mark the second checkbox to indicate such information should remain private. The Patient or the Authorized Representative of the Patient must sign the blank line below these choices to prove his or her declaration in this matter. Under the signature, he or she should enter the calendar date and the current time of day when he or she signed this section of the template. Locate the final area, “IV. Additional Consent For HIV/AIDS,” then either mark the first check box if the Patient will allow for medical records concerning HIV and/or AIDS to be released or mark the second checkbox to indicate the Patient wishes to forbid any such disclosures. The “Signature Of Patient Or Authorized Representative” line must be signed by the Patient or a Representative of the Patient. Additionally, the signature date and time of signature should be supplied to the blank lines “Date” and “Time.”

Related Forms

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

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.

Health Care 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.

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.


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