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Medical Release Form for the United Kingdom

Medical Release Form Template for United States

A Medical Release Form is a legal document used in the United States that authorizes the disclosure of an individual's protected health information (PHI) to designated parties. This document must comply with HIPAA regulations and state-specific privacy laws. It serves as written authorization for healthcare providers to share specified medical information with third parties while protecting patient privacy rights and maintaining regulatory compliance.

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Medical Release Form

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What is a Medical Release Form?

The Medical Release Form is a crucial document in the U.S. healthcare system that bridges the gap between patient privacy rights and necessary information sharing. When healthcare providers need to share patient information with third parties, whether for continuing care, insurance purposes, or legal proceedings, they require explicit authorization from the patient. This form, governed by HIPAA and state-specific regulations, provides that authorization while protecting patient privacy rights. It specifies what information can be shared, with whom, for what purpose, and for how long. The form must include specific elements required by federal and state laws to be legally valid.

What sections should be included in a Medical Release Form?

1. Patient Information: Full legal name, date of birth, contact information, and patient identification numbers

2. Authorization Statement: Clear statement of authorization to release medical information

3. Information to be Released: Specific description of what medical information is authorized for release

4. Purpose of Release: Stated purpose for which the information is being released

5. Duration: Expiration date or event for the authorization

6. Recipient Information: Details of who is authorized to receive the information

7. Patient Rights: Statement of right to revoke authorization and any exceptions

8. Signatures: Patient or authorized representative signature and date

What sections are optional to include in a Medical Release Form?

1. Special Categories Authorization: Specific authorization for sensitive information (mental health, HIV, substance abuse)

2. Legal Representative Authorization: Details of legal representative's authority to sign

3. Re-disclosure Notice: Notice about potential re-disclosure of information

What schedules should be included in a Medical Release Form?

1. Identity Verification Documents: Copies of identification documents used to verify patient identity

2. Legal Documentation: Powers of attorney or court orders establishing legal authority to release information

3. Specific Records List: Detailed list of specific records being authorized for release

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓÆµ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Jurisdiction

United States

Document Type

Authorization Form

Cost

Free to use
Clauses




















Industries

HIPAA: Health Insurance Portability and Accountability Act of 1996 - Includes Privacy Rule requirements, Security Rule compliance, patient rights regarding protected health information (PHI), and requirements for valid authorization

State Privacy Laws: State-specific legislation that may provide additional privacy protections, specific requirements for medical information release, and varying age of consent laws

42 CFR Part 2: Federal regulations providing special requirements and additional privacy protections for substance abuse treatment records

Americans with Disabilities Act: Federal law establishing accessibility requirements and non-discrimination provisions for medical documentation and services

Mental Health Privacy Laws: State-specific mental health privacy laws and special protections for psychotherapy notes

State Medical Records Laws: State-specific regulations governing medical record retention requirements, access rights, and copy fee limitations

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Covers electronic health record requirements and security breach notification requirements

Minor's Rights Laws: Regulations governing parental/guardian consent requirements and special provisions for certain types of care involving minors

EMTALA: Emergency Medical Treatment and Active Labor Act - Establishes requirements for emergency medical treatment and transfer of medical information in emergencies

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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