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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 between 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 – Specific Types

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.

How to Write

Download in Adobe PDF.

Step 1 – Authorization

  • Enter the name of the healthcare provider to disclose protected information to those who have permission to seek such information.

Step 2 – Effective Period

  • The release of said information release shall only cover the periods as stated on the most recently completed form
  • Enter the dates from and to
  • OR
  • All past, present and future periods

Step 3 – Extent of Authorization – Select one of the following:

  • a. Authorization to release of patient’s complete health record to include mental, communicable diseases requiring special care and or treatment of alcohol and/or drug abuse
  • OR –
  • The patient may authorize physicians to release complete health records, except any of the following:
  • Mental health records
  • Communicable diseases
  • Drug/Alcohol treatment
  • Any other (specify)

Step 4 – Once the information has been completed by the patient or by the assistance of a medical professional, the patient must carefully review sections 4 through 8 to ensure that the patient does, in fact, understand all of their rights and that all of their patients’ rights are understood.

Step 5 – Signatures

  • Once the form is completed and understood, the application must be signed either by the patient or their personal representative.
  • Print the name of the patient or representative
  • Date Signature and printed information

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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