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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.

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.

1. 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.

2. 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.

3. 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.

4. When your release form has expired

Release forms usually fulfill one-time needs, such as release 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.

5. 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.

6. 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.

7. 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.

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.

Address

Provide the address of the recipient.

City

Enter the city.

State

Enter the state.

ZIP

Enter the zip code.

Phone

Enter the phone number of the recipient.

Fax

Enter the fax number of the recipient if available.

Email

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.

Signature

Provide your signature

Patient name

Enter your full name.

Date

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.

Signature

Provide your signature.

Patient name

Enter your full name.

Date

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.

Signature

Provide your signature.

Patient name

Enter your full name.

Date

Enter the date when this form is signed.

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