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Fillable Form Medical Release

A medical release form is a document that gives healthcare professionals permission to share patient medical information with other parties.

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What is a Medical Release form?

A medical release form is a document used by healthcare professionals, given your permission, to share your medical information with other parties. Generally, a medical release form is used to help you receive professional care more quickly.

Usually, medical release forms are completed by the physician and patient before treatment starts. However, they may be completed at any time during or after treatment.

A medical release form can be part of an insurance or hospital-related policy if they want to share your medical information with your insurance company.

In some cases, a physician using a medical release form is forbidden by law from discussing specific procedures or patient conditions with an insurance company or other third party without written consent from the patient. In most cases, however, unless you state otherwise on the form, most medical release forms allow any or all of your healthcare information to be shared with any healthcare providers (including your primary care physician), labs, pharmacies, or other medical providers involved in your care.

A medical release form is very important when it comes to the sharing of information between physicians and other medical professionals. This type of document serves as an authorization for these doctors to speak freely about you and your treatment plan without having to get permission from you first. Usually, the only time that a health care professional would need permission from you before disclosing your personal health records or history is if they are not directly treating you or involved in providing patient services for you.

If there are several people working on your case at one point — whether surgeons, specialists, psychiatrists, or others, a medical release form must be completed by everyone. You would use only one medical release form for your entire treatment team, and you should give a copy of this document to every caregiver involved in your case.

In most cases, when one healthcare professional is speaking to another about your history or treatment plan, it's not considered a breach of privacy if they have the other party's personal contact information — including name and phone number. But in some cases, such as sharing very sensitive medical information with someone who may not be directly involved in your care yet needs to know that kind of information for whatever reason, that could be considered a breach of privacy depending on the situation. In those cases, it is also important that anyone discussing patient confidentiality uses their best judgment before disclosing any extremely sensitive information.

As a patient, it is your right to decide who has access to your personal information and the only way to make sure this happens is by knowing in full detail what you are signing when you receive a medical release form from a healthcare provider in any kind of a healthcare setting.

Before you sign anything, be sure that you understand what rights you're giving up in exchange for receiving treatment and always ask questions if something doesn't sound correct or feel right when talking to your doctor or other caregivers about sharing your medical records with someone outside of your current circle of physicians involved in your case. It's important that we all know our rights especially when we need to rely on someone else (like doctors or specialists) for care or treatment when we are in any kind of medical crisis.

If you have specific questions about your rights when it comes to authorizing the sharing of information between your medical team, ask your doctor or other medical professionals involved in your care for more details if you feel the need.

Just keep in mind that most people tend to sign these forms without reading what they actually sign. If you do not want anyone outside of your current circle of doctors and caregivers to have access to sensitive personal health information, then make sure that everyone on your care team knows that this is an important issue for you. And don't be afraid to speak up if anyone tries asking for permission to disclose any extremely sensitive personal health information including specific procedures, diagnosis, treatment, or anything else that is related to your health history.

How to fill out a Medical Release form?

Page 1

Name of patient

Enter your full name.

Date of birth

Enter your date of birth.

Social Security Number

Provide your social security number.

I. Authorization

The Disclosing party

The first line of the authorization process, it states that you are giving authorization to a certain party. Enter the name of the disclosing party.

Check the first box if you are authorizing the party to use or disclose all of your health information.

Check the second box if you are authorizing the party to use or disclose your health information relating to a certain treatment or condition. Provide a description of the treatment or condition.

Check the third box if you are authorizing the party to use or disclose your health information that covers a specific period. Provide the dates.

If you are authorizing the party for other uses, check the last box and indicate them.

II. Extent of authorization

The first line of this section states that the disclosing party may share your information to a recipient.

Name or title and organization

Enter the name or title and organization of the recipient.


Provide the address of the recipient.


Enter the city.


Enter the state.


Enter the zip code.


Enter the phone number of the recipient.


Enter the fax number of the recipient if available.


Enter the email address of the recipient if available.

III. Purpose of the Authorization

Check all the boxes that apply.

Check the first box if the purpose of the authorization is at your request.

If there are any other purposes of the authorization, check this box and indicate the purpose.

Check the third box if you are authorizing the disclosing party to communicate with you for marketing purposes when they receive payment from a third party to do so.

Check the fourth box if you are authorizing the disclosing party to sell your information. If you agree to this, you will receive compensation for your health information and stop any future sales if you revoke this authorization.

Page 2

IV. Termination

Provide the date or situation when the authorization should end.

Check the first box if there is a specific date when the authorization should end. Indicate the date.

Check the second box if the authorization should end when a specific event occurs. Indicate the event.

V. Patient Rights

As an authorizing person, you have the right to revoke this authorization at any time, except when disclosures have already been made based upon your original permission. You cannot revoke this authorization if its purpose was to obtain insurance.

As an authorizing person, you must understand that uses and disclosure already made based upon your original authorization and permission cannot be taken back.

As an authorizing person, you must understand that it is possible for your information may be re-disclosed by the recipient and is no longer protected by the HIPAA privacy standards.

As an authorizing person, you must understand that treatment by any party may not be conditioned upon giving your authorization and you may have the right to refuse to sign this authorization.


Provide your signature

Patient name

Enter your full name.


Enter the date when this form is signed.

VI. Additional consent for certain conditions

This consent states that your medical records may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. You must give separate consent before this information can be released.

Check the first box if you give your consent. Check the second box if you do not give your consent.


Provide your signature.

Patient name

Enter your full name.


Enter the date when this form is signed.

Page 3

VII. Additional Consent for HIV or AIDS

This consent states that your medical records may contain information concerning HIV testing and/or AIDS diagnosis or treatment. You must give separate consent before this information can be released.

Check the first box if you give your consent. Check the second box if you do not give your consent.


Provide your signature.

Patient name

Enter your full name.


Enter the date when this form is signed.

Frequently Asked Questions About a Medical Release Form

When is a Medical Release form used?

A Medical Release form can be used for a variety of reasons, but here are 7 ways that a medical release form is usually used.

When a third party asks for your medical history or information

There are a lot of reasons why a third party may request your medical history or protected health information. For instance, an insurance company may need to create a new life insurance policy for you, or when a family member needs to undergo certain medical treatments.

In these cases, you will need to authorize healthcare providers or hospitals to release your medical information to the party that requests your health history or information. This will give security to you and the healthcare providers that release the information from non-compliance.

There are specific exceptions when you don’t need to sign a medical release form.

  • Health insurance for prior authorization
  • The claims department for claims payment
  • A treating physician or facility

These exceptions are all part of standard healthcare operations and they don’t require you to sign a release form. If they request a release form, it could cause more harm because it could delay payments and compromise patient care.

When your medical information is used for marketing or fundraising

As much as possible, your healthcare provider, or the party that asks for your authorization, should not share any information that may identify you on social media. If people can connect the dots and trace the information back to you, the party that shared this information is violating HIPAA. The same situation applies to fundraising and marketing efforts.

But there are some exceptions. For instance, a children’s hospital usually shows recovering patients in their TV commercials or other advertisement materials when they request donations. Another example is when a patient underwent cosmetic or corrective surgeries or treatments, they may be asked to make a video or written testimonial.

If you encounter these kinds of situations, then you may not need to sign a medical release form.

If you share your experiences face-to-face, you don’t need to sign a release form. For instance, you go to an event and share your experiences.

Before sharing medical information with a research group

Researchers have a hard time breaking through a study without access to medical records. But before sharing your medical history with a research group, you will need to sign a medical release form.

When your release form has expired

Release forms usually fulfill one-time needs, such as releasing medical information to a member of the family in connection to a specific procedure. The form sometimes has an expiration date indicated to make sure that it is not misused in the future.

If your release form is expired and your healthcare provider or another party has to use it for something that is not related to its original purpose, then you may need to sign a new release form.

When you revoke a previously signed form

You can revoke a medical release form at any time. If you decide to revoke a release form, the requesting party needs your authorization for them to use and share your medical information.

When the form is incomplete or inaccurate

Before submitting any form or document, make sure that it is filled out completely and accurately. If you sign a release form that contains incomplete information, that form is invalid and you will need to sign a new one.

When you give permission that is in conjunction with other permissions

Your HIPAA medical records release form cannot be combined with any other authorizations. Parties involved cannot sneak clauses into a form or in this case, the authorization that you grant them can only be applied for a specific purpose.

If a requesting party mistakenly combines forms and permissions, then they will need to request new authorization from you for them to be able to share your medical records.

What is authorization to release medical information?

An authorization to release medical information is a document that grants a patient's physicians or other healthcare providers permission to disclose their medical records and other health information to another individual, entity, organization, or business. An authorization form is usually given directly from the patient to the recipient of the medical information.

The release of medical information may be necessary in order for a physician or healthcare provider to provide treatment or advice to a third party who has been authorized by the patient themselves. In cases where a patient is incapacitated and gives no one permission to access their records, companies will often rely on an attorney's power of attorney when needing access to that person's health history in order to offer any sort of life insurance. Once the company receives this document it can request all former medical records from doctors and specialists under the power of attorney.

A patient may also need to release their health records for other reasons, such as when filing an insurance claim or when applying for disability benefits. In the case of litigation, either civil or criminal, a medical authorization allows parties involved access to any and all necessary information in order to build a strong defense or seek damages that result from the alleged incident. A subpoena is not needed in these cases because that would violate doctor-patient confidentiality rules and regulations set forth by HIPAA laws.

The two main types of authorizations are:

  1. Pre-existing authorizations — Those forms completed prior to treatment; and
  2. During-treatment authorizations – Those forms completed by patients while receiving care.

Both kinds require written permission and, except in emergencies, must be notarized to prevent unauthorized access or use of the information or both. In addition to authorizing the release of existing medical records for treatment purposes, a pre-existing form also permits disclosure of health information for billing or insurance purposes.

What is the difference between a medical release form and a medical consent form?

A medical release form and a medical consent form are two documents that can be easily confused, yet they are used for completely different purposes. A medical release form is designed to allow the holder of records or information to make a decision about whether patient information can be shared with another party. A medical consent form is designed to obtain approval from the patient to share their medical information with another party.

A release form allows the licensed healthcare provider or any other party holding client records (i.e., insurance company) to provide patients' health information for treatment, payment, and health care operations without written authorization from each individual who is the subject of that data. A consent form seeks permission from the person whose medical information will be released for this purpose. The consent form should be offered after the patient has received all of the relevant information that would include who will have access to the records, how they may be used, and what might happen if the information is withheld.

Both forms are designed to protect private data from being shared inappropriately. However, it is important for healthcare providers to realize that a release form can only be signed by an individual with proper authorization to give permission for their health information to be released. A patient's legal representative cannot sign a release form on behalf of their loved one without an express power of attorney. If there are any questions regarding this matter, it is best to consult with an experienced healthcare practitioner or your state's department of public health.

Conversely, a consent form can usually be signed by any individual who is at least 18 years of age. If the patient is a minor, then written permission from the parent or guardian may be required. Once signed, a consent form becomes a legal contract between the healthcare provider and the patient allowing for all patient medical records to be shared with another party for their own purposes.

In conclusion, it's important to realize that both forms are critical in protecting patients' private data; however, only the consent form legally allows information to be released without specific written authorization. Like other contracts, these forms should always include certain key components such as signing dates and times, agreement terms (i.e., type of record), client name (if different than signer), and contact information for the patient.

Why are medical release forms important?

Medical release forms are important because they protect patients from being exploited in the medical industry. Every patient should be aware that any test or procedure done on them without their consent is a violation of their rights and could lead to legal consequences for the doctor or staff involved.

On the other hand, medical release forms are used by doctors to clear themselves from liability in case something happens to a patient during treatment and it is determined that the doctor did not do enough to protect against such circumstances. A properly filled out and signed form includes information that lets a doctor, nurse, or hospital staff know what type of person they're treating and what expectations should be set in terms of possible side effects and risks before procedures can begin.

For example, if someone goes in for surgery because they need their appendix removed, but when the surgeon gets inside they realize that the patient has cancer instead, they would want this information on hand so they could abort the surgery immediately.

Before any procedure is done on a patient, the doctor will ask for a medical release form to be filled out and signed that specifies what tests have been done in the past, what medications they're currently on, if they have any allergies or chronic medical conditions, and whether or not there is anything else about their history that is relevant to this particular surgery.

Medical release forms are beneficial to both the patient and his or her doctor. They protect the patient by giving them much-needed information before any procedures can begin, and they protect the doctor by making sure he or she is fully aware of what to expect when operating on someone. Moreover, they protect both parties by making sure that the doctor knows what their patient's wishes are, and if anything were to go wrong during a medical procedure, such as surgery, consent forms help establish whether or not the doctor did everything he or she was supposed to do.

What are the other names of a medical release form?

A medical release form has other names such as a waiver form, consent form, or medical authorization form. It's an important document to have when you are visiting a new doctor on your own. They differ in names, but they all have the same function — to allow a patient to receive medical treatment and help the doctor do his job.

Can a patient give verbal consent to release information?

According to HIPAA, a patient can give verbal consent to release information and not use a medical release form only when all of the following are true:

The consent is limited to only the Protected Health Information that is directly relevant to providing care. The information is limited in scope and duration. The verbal request for information occurs during a face-to-face encounter with the covered entity or its representative.

The patient can revoke his or her consent at any time, but this revocation does not override any legal obligation to which the covered entity is subject under federal, state, or local law. For example, HIPAA does not affect requirements mandated by other laws related to reporting child abuse cases. If you suspect physical abuse of your child(ren), you will need to provide written permission (i.e., use a medical release form) an oral statement that meets all of the HIPAA requirements is not enough.

In general, you will need written permission from your patient to provide his or her medical records to anyone else, including an insurance company or family members who are seeking treatment for your patient. In other words, even if your patient gives you oral permission to share his or her data with another healthcare provider or payer, doing so would violate HIPAA unless he or she provides you with written permission in advance and included in his or her chart.

Another important point is when obtaining consent verbally during face-to-face, patients must sign and date the medical release form immediately after giving their verbal consent. They must also receive a copy of the completed document.

A final point: if your patient is incapacitated, there are only two ways you can obtain his/her permission to share information with another healthcare provider or payer:

  • Ask the authorized "representative" for the patient; or
  • Consult with an ethics committee at your facility about obtaining implied consent from someone who has temporary power of attorney over the incapacitated patient's affairs.

How long is an authorization to release medical information good for?

An authorization to release medical information is only good until the patient changes their mind.

It's common to see release forms that call for an expiration date or one year from the last day the form was effective, but patients can revoke such forms at any time and you must honor such requests.

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