Free Medical Records Release

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Create Your Free Medical Records Release

Answer a few simple questions
Email, download or print instantly
Just takes 5 minutes

Medical Records Release

Patient Details

Full Name:

Date of Birth:

Address:

e.g. Street, City, State ZIP Code, etc.

Home Phone Number:

Cell Phone Number:

Email:

Is the patient a minor or dependent adult? A minor is someone who is under the age of majority in their residing state. For example, in the state of Montana the age of majority is 18. A dependent adult includes someone who is under another’s care by way of medical directive, power of attorney, court order, etc.

Yes

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Frequently Asked Questions

Who is the patient?The patient is the individual seeking to have their own medical records released.

Your Medical Records Release

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MEDICAL RECORDS RELEASE

THIS MEDICAL RECORDS RELEASE (the "Release") is made July 20, 2018.

TO:	______________________________, ______________________________ Phone: ______________________________, Fax: ______________________________ and all employees, contractors, and associated individuals thereof;

TAKE NOTICE THAT I, ________________________________________ (the "Patient"), do hereby request the following information be released:

Medical Records

1. All medical and health information contained within:

Charts;
Notes;
Reports;
Records;
Medication lists, and other lists;
Prescriptions;
Flowcharts;
Emails;
Memorandum;
Orders;
Lab results;
Test results, and analyses:
Information related to treatment for any sexually transmitted disease, including HIV or AIDS;
Information related to treatment for mental health illnesses;
Information related to treatment for substance abuse;
Diagnostic images and reports, including but not limited to X-Rays and EKG tracings;
Photographic images; and
Digital recordings, including but not limited to digital images.

1.2 All information related to the accounting of the Patient’s files, including but without limitation to Statements of Account.

1.3 All other authorizations previously received for the release of any or all of the Patient’s medical information.

1.4 All of the above is collectively referred to as “Medical Records”, as represented on paper, kept in folders, orstored digitally, electronically, or any other form.

1.5 "Medical Records" also includes production of any documents or material by physicians, nurses, chiropractors, dentists, therapists, counselors, consultants, technicians, and any and all staff of the organization to which this Release is directed.

Disclosure

2. I ask that the Patient’s Medical Records be released to me, for my own personal use.

2.2 I am aware of the potential for information disclosed pursuant to this Release to be subject to redisclosure by me and so may no longer be protected.

Time

3. I ask that the Patient's Medical Records be released within the next 30 days as required by the Health Insurance Portability and Accountability Act.

Notice and Additional Information

4. The contact information and particulars of the Patient are as follows:

Name:	________________________________________
Date of Birth:	July 20, 2018
Street Address:	________________________________________
Home Phone Number:	________________________________________
Cell Phone Number:	________________________________________
Email:	________________________________________

Duration of Medical Records Release

5. This Release will be valid until the earlier of when you receive written notice from me revoking this Release, or July 20, 2018.

Continuance of Ongoing or Future Care

6. This Release does not affect any ongoing or future care of the Patient.

SIGNED at ________________________________________, ________________________________________ in the presence of:

______________________________
WITNESS

__________________________
PATIENT/LEGAL REPRESENTATIVE

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Medical Records Release Information

Alternate Names:

A Medical Records Release is also known as a:

Medical Records Authorization

Request for Medical Records

Medical Records Request

What is a Medical Records Release?

A Medical Records Release is a document used by an individual or their representative to release their personal medical records to another party.

Who are the parties in a Medical Records Release?

There are four main parties in a Medical Records Release, depending on your situation.

Patient. The patient is the person who has received medical treatment in relation to the records that are to be released.

Guardian/Legal Representative. A guardian or legal representative is the person who authorizes the release of said records on behalf of a minor or mentally or physically incapacitated adult.

Organization. The organization is where the records are currently held. This could be any type of medical facility, such as a hospital, clinic, doctor's office, massage therapist, chiropractor, etc.

Organization or individual that requires access. If the medical records will be shared, this is who they will be shared with. Often, lawyers, insurance companies, or employers are the organizations or individuals who are requesting the records.

What information is included in a Medical Records Release?

A Medical Records Release includes information about the patient or their representative, the organization who holds the records, and the organization or individual requesting access.

If the records require corrections, you may also indicate what the errors are.

It will also include details about the duration of the release, should you choose to set an end date. It is recommended that you choose an expiration date that is less than two years from the date your release is issued.