HIPAA Medical Records Release Form (Overview)

HIPAA is an abbreviation of the Health Insurance Portability and Accountability Act. The act is a federal law that was created in 1996 to protect sensitive patient data and other related information from being disclosed without the patient’s knowledge. Also, the act provides liability for each person who accessed such information to avoid sharing it with others.

HIPAA works hand in hand with Medical Record Information Release forms to protect and safeguard patient’s sensitive information. In its simplest definition, Medical Record Information Release allows the patient only to provide a list of names of people they feel should access their patients’ records under any circumstances.

HIPAA generally protects;

  • An individual’s past, present, future physical or mental condition records
  • The provision of healthcare to individual records
  • The payment of medical expenses used in the past, present, or future health care services records

Things the Authorization Form Must Specify

Usually, there are some mandatory things that must be included in a medical records release authorization.

These include:

  • A description of the protected health information to be used or disclosed
  • The person authorized to make use or disclosure.
  • The person to whom the covered entity may make disclosure
  • An expiration date 
  • Patient information requested in the introduction
  • Document who may receive information
  • Report the type of information your agent may receive, use, and dispense
  • Discuss the purpose of this authorization
  • A valid authorization signature from the patient must be present
  • Additional sensitive items may be authorized at the patient’s discretion

Applicable Laws

There are various laws that govern the use and access to patient’s private information.

These mainly include the  45 C.F.R. Part 160 and 45 C.F.R. Part 164 that are explained below;

The 45 C.F.R. Part 160 provides comprehensive federal protection of the health information and how it used to be used, carried, or disclosed. The major subparts that pay the most attention include subparts A and E. 

Similarly, this section of the law provides guidelines on the protection of electronic health information as well as administrative standards and security. 

Note: in as much as these acts stipulates strict measures to protect patient information from unauthorized persons, they are carefully balanced hence cannot interfere with patient access to receiving quality health care services. 

Types of HIPAA Medical Records Release Authorization Forms

Generally, HIPAA Forms can be categorized according to the type of information required or disclosed.

In that line of thought, here are some common HIPAA medical release forms you are likely to get:

  1. Standard form
  2. Dental (A.D.A.) HIPAA Form
  3. Chiropractic HIPAA Form
  4. Medicare HIPAA Form (CMS 10106)

Revocation of the Authorization Form

Usually, authorization of HIPAA can happen at any time by the patient. Depending on the patient’s choice and decision, they can always revoke or terminate the decision to disclose their health information to people/individuals previously authorized to receive such information. However, such revocation should always be done in writing. Also the revocation only becomes effective when the covered entities receives the form. Once such authorizations are revoked, the previously authorized agents will no longer allowed to receive patient’s information.

Fee to Release Medical Records

The fee to release HIPAA medical records may depend on the medical office you are attached to. However, there are some situations where you may be charged for transferring medical records from one point to the other. Nonetheless, you should bear in mind there is a limit for such a fee.

To know the fee charged in your respective state, you can take a look at the table below:

StateMaximum Fees ($)Laws
AlabamaFee imposed on search: $5 Pages 1-25: $1/page Pages 26+: $0.50 Other Necessary Documents: Actual reproduction cost.The charges ranges from $ 12-21-6.1
AlaskaNot applicableThere is no Statute in place
ArizonaRecommendable FeeCharges range from $ 12-2295
ArkansasFee imposed on search: $15 Pages 1-25: $0.50/page Pages 26+: $0.25/page$ 16-46-106
CaliforniaFee associated with search: $4 Evidence Fee: $15 Pages 1+: $0.10/page Microfilm: $0.20/pageEVID Code $ 1158(2) & $ 1563(6)
ColoradoFee imposed on search: $18.53 flat fee (First ten pages) Pages 11 – 40: $0.85 each page Pages 41+: $0.57 each page Microfilm: $1.50 each page6CCR 1011-1 Chapter 2 Part 5.2.3.4
ConnecticutPages 1+: $0.65 each page$ 19a-490b
DelawarePages 1 – 10: $2.00 each page Pages 11 – 20: $1.00 each page Pages 21 – 60: $0.90 each page Pages 61+: $0.50 each page Microfilm: Actual cost of reproduction.Title 24: Chapter 1700, Section 29
FloridaFee imposed on search: $1.00 (Each year each request) Pages 1+: $1.00 each page Microfilm: $2.00 each page$ 395.3025 (1)
GeorgiaFee imposed on search: $25.88 Pages 1 – 20: $0.97 each page Pages 21 – 100: $ 0.83 each page Pages 101+: $0.66 each page Certification Fee: $9.70$ 31-33-3
HawaiiRecommendable Fee$ 622-57(g)
IdahoN/ANo Statute
IllinoisFee imposed on search: $29.09 Pages 1 – 25: $1.09 each page Pages 26 – 50: $0.73 each page Pages 50+: $0.36 each page Microfilm: $1.82 each page735 ILCS 5/8-2005
IndianaFee imposed on search: $20.00 (includes first 10 pages) Pages 11 – 50: $0.50 each page Pages 51+: $0.25 each page Affidavit/Certification: $20.00760 IAC 1-71-3(a)
IowaRecommendable Fee$ 622.10
KansasRecommendable FeeREVOKED
KentuckyFirst (1st) Copy: Free Second (2nd) Copy: $1.00 each page$ 422.317
LouisianaFee imposed on search: $25.00 Pages 1 – 25: $1.00 each page Pages 26 – 350: $0.50 each page Pages 351+: $0.25 each page Max Fee for Electronic Records: $100.00 each request$ 1165.1
MaineFee imposed on search: $5.00 (Includes first page) Pages 2+: $0.45 each page Max Fee: $250.00 Max Fee for Electronic Records: $150.00 each request$ 1711-A
MarylandFee imposed on search: $22.88 Pages 1+: $0.83 each page Electronic Records Fee imposed on search: $22.88 Electronic Records Pages 1+: $0.62 each page Max Fee for Electronic Records: $81.63 each request$ 4-304
MassachusettsFee imposed on search: $25.01 Pages 1 – 100: $0.84 each page Pages 100+: $0.43 each page Social Security: No charge for a request to support a claim under the social security act.Title XVI, Ch III, Section 70
MichiganFee imposed on search: $25.38 Pages 1 – 20: $1.27 each page Pages 21 – 50: $0.63 each page Pages 51+: $0.25 each pagePublic Act 47 of 2004. MCL 333.26269
MinnesotaFee imposed on search: $19.19 Pages 1+: $1.44 each page X-rays: $10 Fee imposed on search plus the actual cost of reproduction.$ 144.292
MississippiFee imposed on search: $20.00 Flat Fee (first 20 pages) Pages 21 – 100: $1.00 each page Pages 101+: $0.50 each page Search/Storage Fee: $15.00 (Only charged if records are retrieved from off-site location) Certification Fee: $25.00$ 11-1-52
MissouriFee imposed on search: $26.06 Pages 1+: $0.60 each page Storage Fee: $24.40 (Additional fee if records are retrieved off-site) Max Fee for Electronic Records: $114.17$ 191.227.5
MontanaFee imposed on search: $15.00 Pages 1+: $0.50 each page$ 50-16-540
NebraskaFee imposed on search: $20.00 Pages: 1+: $0.50 each page X-rays: Actual cost of reproduction.$ 71-8404
NevadaPages 1+: $0.60 each page X-rays: Recommendable Fee$ 629.061
New HampshireWhichever is greater: $15 for first 30 pages or $0.50 each page
X-rays: Recommendable Fee
$ 332-I
New JerseyFee imposed on search: $10.00 Pages 1 – 100: $1.00 each page Pages 101+: $0.25 each page Max Fee: $200.00$ 8:43G-15.3,  $ 13:35-6.5
New MexicoPages 1 – 15: $30.00 flat fee Pages 16+: $0.25 each page X-rays: Actual cost of reproduction.$ 16.10.17.8
New YorkPages 1+: $0.75 each page X-rays: Actual cost of reproduction.Title 2: Section 17
North CarolinaPages 1 – 25: $0.75 each page Pages 26 – 100: $0.50 each page Pages 100+: $0.25 each page Minimum Fee: $10.00$ 90-411
North DakotaFee imposed on search: $20.00 (Includes pages 1-25) Pages 26+: $0.75 each page Electronic Records Fee imposed on search: $30.00 (Includes pages 1-25) Electronic Records Pages 26+: $0.25 each page$ 23-12-14
OhioFee imposed on search: $20.42 Pages 1 – 10: $1.34 each page Pages 11 – 50: $0.69 each page Pages 51+: $0.27 each page X-rays: Fee imposed on search plus $2.27 each page$ 3701.742
OklahomaFee imposed on search: $10.00 Pages 1+: $0.30 each page X-rays: $5.00 each page Max Fee: $200.00$ 76-19
OregonFee imposed on search: $30.00 (Includes pages 1-10) Pages 11-50: $0.50 each page Pages 51+: $0.25 each page X-rays: Actual cost of reproduction.OAR 847-012-0000
PennsylvaniaFee imposed on search: $23.45 Pages 1 – 20: $1.58 each page Pages 21 – 60: $1.17 each page Pages 61+: $0.40 each page Microfilm:  $23.45 + $2.33 each page48 Pa.B. 7712
Rhode IslandPages 1 – 10: $2.50 each page Pages 10 – 50: $0.75 each page Pages 51+: $0.50 each pageR5-37- MD/DO Section 11.2
South CarolinaFee imposed on search: $26.67 Pages 1 – 30: $0.69 each page Pages 31+: $0.53 each page Max Fee for Electronic Records: $160.05$ 44-115-80
South DakotaNo Current Fee Schedule$ 36-2-16
TennesseeFee imposed on search: $18.00 (Includes pages 1 – 5) Pages 6 – 50: $0.85 each page Pages 51 – 250: $0.60 each page Pages 251+: $0.35 each page$ 63-2-102
TexasFee imposed on search: $48.77 (Includes pages 1 – 10) Pages 11 – 60: $1.64 each page Pages 61 – 400: $0.80 each page Pages 401+: $0.44 each page$241.154
UtahFee imposed on search: $21.16 Pages 1 – 40: $0.53 each page Pages 41+: $0.32 each page78B-5-618
VermontWhichever is greater: $5 or $0.50 each page Social Security: No charge for a request to support a claim under the social security act.$ 9419
VirginiaFee imposed on search: $20.00 Pages 1 – 50: $0.50 each page Pages 51+: $0.25 each page Max Fee: $150.00 Electronic Records Fee imposed on search: $20.00 Electronic Records Pages 1 – 50: $0.37 each page Electronic Records Pages 51+: $0.18 each page Electronic Records Max Fee: $150.00 Microfilm Fee imposed on search: $20.00 Microfilm Pages 1+: $1.00 each page$ 8.01-413
WashingtonFee imposed on search: $26.00 Pages 1 – 30: $1.17 each page Pages 31+: $0.88 each pageWAC 246-08-400
West VirginiaFee imposed on search : $20.00 Pages 1+ : $0.40 each page Pages 1+ Electronic Records: $0.20 each page Max Fee Electronic Records: $150$ 16-29-2
WisconsinFee imposed on search: $22.61 Pages 1 – 25: $1.14 each page Pages 26 – 50: $0.86 each page Pages 51 – 100: $0.56 each page Pages 101+ $0.34 each page Microfilm and other media: $22.19 + $1.68 each page X-rays : $22.19 + $11.28 each series Certification (if not patient or their representative): $9.04 per request$ 146.83 (3f)(c)2
WyomingNot applicableThere is no act yet

Download Templates

Download free customizable templates here.

HIPAA-Medical-Release-Form-01_

HIPPA-Medical-Record-Release-Form-02_

    Templates by State

    FAQs

    How long is a medical release form good for

    Depending on the state, a medical release form should specify the expiration date with a clause. However, the majority of these forms are often good for a period of 90 days.

    Does a release of information need a witness

    No. you don’t necessarily require a witness to notarize authorization forms. However, making your release forms signed in front of a witness is an extra step, but not a mandatory one.

    How long is a HIPAA valid

    HIPAA does not have a specific time for validation. Usually, its validity can be revoked at any time by the patient through writing.

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