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MEDICAL RECORDS RELEASE
THIS MEDICAL RECORDS RELEASE (the "Release") is made November 21, 2019.
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:
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:
November 21, 2019
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 November 21, 2019.
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
A Medical Records Release Form is also known as a:
A Medical Records Release Form is a document used by an individual (or their representative) to release personal medical records to another party.
A Medical Records Release Form typically includes information about:
If there are any errors in the records, individuals can also include details about the errors (such as where the errors are located) and the corrections.
A Medical Records Release Form often involves four main parties, depending on the situation:
The patient. The patient is the person whose medical records are being released to another party; this is often the person who received or is receiving some type of medical treatment in relation to the records that are to be released.
The guardian. A guardian (or legal representative) is only involved when the records relate to a minor or a dependent adult (such as an adult who has mental disabilities). Minors and dependents cannot authorize their own medical release, so a guardian is required to do so on their behalf.
The organization holding the records. This is where the records are currently being held. This could be any type of medical facility, such as a hospital, clinic, doctor's office, massage therapist, etc.
The organization or individual that requires access. In some instances, medical records need to be shared with organizations or individuals such as lawyers, insurance companies, or employers.
For example, if you were injured in a motor vehicle accident and required physiotherapy, your physiotherapist may be required to provide your lawyer or insurance company with information about your injury and would require a Medical Records Release Form to do so.
The Health Information Portability and Accountability Act (HIPAA) has rules in place to protect health information from being improperly used or disclosed. When someone requests access to your medical records, HIPAA requires that they obtain your consent.
Using a Medical Records Release Form helps prevent the release of medical records to unauthorized parties and helps keep your information confidential.
When creating your Medical Records Release, you can set an end date that will invalidate the consent form once that date has passed. A Medical Records Release Form can remain valid for years or even decades; however, it is highly recommended that you limit the validity of your Medical Records Release Form to two years or less in order to help prevent unauthorized disclosure of your medical records.
Sample
Medical Records Release
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