Free Medical Release Forms

There are two types of medical information release forms, the first includes the one that allows your medical practitioner to release medical information to you and the second authorizes someone to do treatment of your child or family member when you’re not around. A medical information release form gives permission for the release of your medical records.

Both types have a different format. We will go step by step to create each type of form.

Doctors cannot access your medical history without the consent of the patient. if the medical practitioners want to view the records of the patients then they need to get consent from the patient first. A medical record is considered private and confidential.

Step 1: Print your date of birth, social security number, and maiden name.

At the top of your form, there should be a place to write your DOB, SSN, and maiden name. These will be useful in giving credit to the staff at the hospital that has requested the medical form. This will also prevent the wrong information from being printed in the form.

Step 2: Give Permission

The next step in form is to give permission. Write down a paragraph that you have given the authority to the medical practitioners and the hospital staff to release your medical forms. This can serve as written evidence that you have given consent for the release.

Step 3: Specify the Limitations

Write whether you want all your medical history to be released or just a part of it or to a specific period of time. You can choose to have all your health care information released or not released.

Step 4: Private information

Your private information should be private. In a note, state what you NOT want to be released. For example, state to not the release of sexually transmitted infections or HIV/AIDS. Or write whether you want your mental health, state, or addictions released as well.

Step 5: State the period

Specify when the release is valid. i.e for 90 days, specify it at the bottom of the form.

Step 6: Sign

 Put a signature and your name on the form, at the bottom. It serves as evidence.

2nd Type: Child Medical Treatment Form

Step 1: Type and Print an Authorization Statement

Type and print a statement that shows you have allowed your caretaker to get medical treatment for your child. It serves as a medical authorization letter. It protects your caretaker from any legal action in case anything happens to your child.

Step 2: List of Medical Conditions

Write all the medical conditions that medical practitioners should be aware that your child has. Include the disease allergies and handicaps.

Step 3: Include the Name of Your Child’s Doctor.

 In case your child could be having a specific doctor, write it down. This will allow for a follow-up to ensure that your child’s medical history is clearly understood for proper treatment.

Step 4: Include Your Contacts

In your form, write your phone number and your location, either, including your workplace. In case of anything, it will be easy to make a follow-up.

Step 5: Sign

Put your signatures, name, and date at the end to make it valid.

Free Forms & Templates

Sample of Medical Information Release Form

Sample Authorization Form to Disclose Health Information

Blank Medical Records Release Form

Blank Authorization Form to Release Health Information

Blank Authorization Form to Release PHI

Medical Records Release Form Template

Medical Records Release Form Template 02

Medical Records Release Form Template 03

Medical Records Release Form Template 04

Medical Records Release Form Template 05

Medical Records Release Form Template 06

Medical Records Release Form Template 07

Sample Authorization Form to Release Medical Record 01

Sample Authorization Form to Release Medical Record 02