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45 Free Medical Record Release Forms (HIPAA) | Word – PDF

The HIPAA medical record release form allows you to identify those individuals to whom you would like your medical information disseminated and protect your information from unauthorized persons. Anyone who contacts a healthcare provider whose name is not listed on the medical record release form can not access any medical information regarding the patient. Its primary purpose is to protect patient privacy while permitting healthcare information to be exchanged freely between authorized individuals for certain health-related activities.

Alternatively and generally,  medical record release forms are called;

  • Medical Authorization
  • Authorization to Disclose Health Information
  • HIPAA Release
  • HIPAA Authorization

Free Templates

Download free customizable HIPAA medical record release form here:

medical record form pdf

types of medical records pdf

    Templates for All States

    Following provided is the medical record release form for every state:

    Applicable HIPAA Law

    The Health Insurance Portability and Accountability Act (HIPAA) is a federal law of the United States that defines the requirements for treating protected health data of individuals. HIPAA compliance is regulated by the HHS (Department of Health and Human Services), and the Office for Civil Rights is responsible for enforcing it.

    HIPAA compliance must be an integral part of the corporate culture of every entity operating in the healthcare sector to ensure the privacy, security, and integrity of protected healthcare data

    The HIPAA law was passed by the US Congress and became law with the signature of President Bill Clinton in 1996. This rule has been in effect since April 14, 2001.

    HIPAA release law was initially enacted for modernizing the flow of health information; regulating the processing of personal identification data (PID) by companies in the health and health insurance sector to prevent theft and fraud, and in overcoming limits in medical insurance coverage in terms of portability and coverage of people with pre-existing medical conditions. Keeping health information confidential is an essential component of modern healthcare. Another key element of HIPAA is the Security Rule, which is part of the privacy rule. This sub-group includes all those personal health data that each entity includes, generates, receives, stores, or transmits electronically.

    Fundamental principles of the security rule are:

    • Maintain the confidentiality, integrity, and availability of all protected health information in electronic format.
    • Identify possible threats to safeguard confidential information.
    • Protect data from possible disclosure or illegal use.
    • To certify the compliance of the person who at any level comes into contact with such data.

    Any demographic information that allows identifying a patient or client of an entity covered by HIPAA is called Protected Health Information (PHI). Some examples of PHI are such as names, addresses, telephone numbers, social security numbers, medical records, financial information, and close-up facial photos, to name a few.

    Under the Privacy Rule, patients can also personally obtain access to the information that has been documented and protected using the HIPAA medical record release form maintained by their healthcare providers. They can access the data in a covered entity’s designated data set (a group of records maintained by the covered entity used to make healthcare decisions). If a patient finds that the information a covered entity holds is inaccurate, he or she may request an amendment.

    Apart from that, the patient permitting their medical records to somebody else to be released has the liberty to revoke the form at any point in time that they feel the need to. Under HIPAA medical release federal law, a patient must write and sign a medical record release form before his/her protected health information is disclosed by anyone other than for the purposes provided in 45 CFR § 164.500   covered explicitly in 45 CFR § 164-508

    These include:

    • Victims of domestic violence or assault
    • Judicial and administrative processes
    • Organ harvesting from cadavers, cornea, or tissue donations
    • Compensation of workers

    How to Get Medical Records

    Under   45 CFR 164.524(b)(1), a medical record release form will usually be required to obtain a copy of your medical records if you or somebody else seeks them from a doctor or a medical facility either for yourself or a third party requires them for you. Once you have requested the records, you may have to wait a while for them to arrive.

    Request the medical records

    In order to attain medical records, a medical records release authorization letter will need to be written. The medical records release authorization letter requesting the medical records that you will write should include the following sections:

    • Releaser and recipient details: The first section o the authorization letter provides the name of the releasor, who has the medical records, and the recipient who will receive them.
    • Time period: The time period in the letter indicates the date on which the release of the medical record will be authorized as well as the duration for which it will be valid.
    • Type of medical records: Medical records can be of any specific treatment or of all the treatments a person has undergone. This section in the letter specifies which type of records a person is requesting.
    • Expiration date: The expiration date is mentioned on the letter requesting medical records, after which the letter becomes invalid to avoid any illegal use of the records.

    Example letter

    Dear ABC,

    I am contacting you to request a copy of my medical records. On 15/05/2012, I received treatment at your office, and I require you to provide all charts, test results, and consultation notes, as well as all referrals.

    A copy of my medical records may incur a reasonable fee. However, the amount charged for the time spent in locating the records is not refundable. Please mail the required information to the above address. Attached is a self-addressed envelope for my convenience.

    Please note that postage is extra.

    Best Regards,



    Sending the letter

    Whenever sending the letter to the medical facility, it is best to include instructions on how the records are to be sent, such as an electronic document (PDF or Word), through the mail or fax. The medical facility may charge a fee for sending the records while prohibited from charging for processing the request.

    Expecting response

    Today’s medical facilities are generally aware that time is of the essence when assessing an individual’s medical records. In this case, the information requester should call or ask a representative of the transfer status if the requested information has not been received within 5 to 7 working days.

    The medical facility cannot keep medical records beyond the initial 30-day period. If the initial 30 days are not met, an additional 30-day extension can be granted only after receiving a written letter by the healthcare provider that will be necessary and will be stating why the transfer remains delayed according to 45 CFR 164.524. Although state laws vary, typically, delivery typically takes place within 30 days. Only one extension period is allowed to be given to the healthcare provider.

    Who Can Request the Form on Your Behalf

    Whether it is a family member, friend, lawyer, or unrelated party, an individual may appoint a personal representative who will act on your behalf when making decisions about your health care under  45 CFR § 164.502(g). This individual can take care of payment and treatment issues.

    The following can request the medical record release form on your behalf:

    Option 1: Personal representative

    A patient who is incapacitated or unable to make good choices may be considered severely disabled. In that case, their representatives can request medical records. Additionally, people who have been appointed by a court to act as caregivers or guardians addressed as “agent” or “attorney in fact” in a medical power of attorney form from time to time are entitled to receive medical records following the judicial code through the HIPPA medical record release form. Representatives may be physicians, other health professionals, or someone responsible for reviewing the record and informing you of its contents.

    Personal representative in case of injury

    The purpose of a medical record in a personal injury case by a legal representative is to prove the occurrence of the injury, calculate damages, determine the cause of the injury, and determine whether the health provider used reasonable care in case it is needed in court to file a lawsuit or for other legal purposes. While providing care to get access to medical records, a medical record release form is required by the legal representative/attorney.

    Option 2: Adult or legal guardian

    Adults and legal guardians can access the medical records of a child until he/she turns 18, but in several states of the US, it is now prohibited, and to access the records, the guardian has to use the medical record release form.

    Option 3: Administrator of an estate

    A deceased patient’s medical records can only be accessed by the executor or administrator of the estate. A patient’s estate executives are named in their Will, while administrators are appointed by the court when no Will exists. The estate administrator can use a HIPAA medical record release form to request access to the medical records in most cases

    Health providers are required to make sure that information is released only to individuals or organizations with appropriate authorization. Failure to use a release of information will lead to the health provider not disclosing the information.  

    General Parties that can Require it

    Although there are a few parties enlisted above that can require a principal’s medical records on their behalf with the help of a HIPAA medical record release form in case he or she is incapacitated or in need of such records for treatment, there are a few parties that can and may generally require these records for their personal purposes related to your health. According to  45 CFR § 164.502(g), an individual may request medical records on behalf of another entity.

    Such parties that may require the medical record release form include;

    Insurance companies

    When evaluating claims, insurance companies often request medical records. The insurance company does not have a right to view your medical records, which is why they need a HIPAA medical release form to gain access. Still, without your medical records, your claim may be denied, and because of that, insurers can access medical records.

    Treatment providers

    Medical records are requested in case of continued treatment, and that is why they are considered essential. Doctors may need the medical records to check your medical history and the quality of the medical care you have received in the past to continue your treatment, and for that, they need a HIPAA medical record release form.


    An employer can request a doctor’s note with the help of a medical record release form if they need the information for sick leave, workers’ compensation, wellness programs, or health insurance. Moreover, in some cases, the employer can request the medical records if the job is physical and requires tests. However, if the employer asks health care providers directly for information, one’s provider cannot give the employer the information without authorization using the medical record release form.


    Researchers conducting clinical trials and medical studies use this identifiable information to conduct research. It can also be requested, along with the medical history and the medical record release form.

    Medicinal marijuana provider

    In many states, your doctor will note your need for medicinal marijuana in your records. If a dispensary requires an additional proof, they may be asked for medical records. The medical record release form may serve as additional proof if required by a dispensary.

    Consequences of Not Using the Form

    Since the main purpose of the HIPAA medical record release form is to release a patient or individual’s medical records to third parties such as authorized individuals or organizations in different scenarios.

    One of the major consequences of not having a HIPAA medical records release form subscription is that in case somebody wants to share their medical records with somebody else, the health providers will firstly not share them with that party as they will have no proof of authorization and in case the health providers release this information without proof and they could be liable to legal consequences.

    Secondly, an individual would not be able to keep track of or sue anybody who tries to gain access to his or her medical records in an inappropriate and unauthorized manner without using the medical record release form.

    Frequently Asked Questions

    What information can be found in the medical records?

    The medical records document details the patient’s history, clinical findings, diagnostic test results, pre and post-surgical care, patient’s progress, and medications. If written correctly, records inform the doctor about the correctness of treatment.

    Will I have to pay for the medical records?

    Medical offices can charge for copying and transferring records. However, smaller medical offices tend not to charge for this service. If patients request different copies of their medical records as permitted under the Privacy Rule, they can be charged for copies.

    Why is it important to correct errors contained in the medical records?

    Patients are legally entitled to their records, including doctors’ notes, and ask for corrections if needed. Re-examining records for accuracy can lessen the risk of misdiagnosis, duplication of testing, improper care, and letting medical identity thieves get away with identity theft.

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