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Medical Records Release Authorisation Form for the United States

Medical Records Release Authorisation Form Template for United States

A standardized legal document compliant with U.S. federal regulations, particularly HIPAA, that enables patients or their authorized representatives to grant permission for the release of their medical records to specified recipients. This document serves as a formal authorization mechanism that healthcare providers must obtain before sharing protected health information. It includes specific requirements for patient identification, the scope of information to be released, duration of the authorization, and clear statements about the patient's rights regarding their medical information. The form must comply with both federal privacy laws and any additional state-specific requirements in the United States.

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Medical Records Release Authorisation Form

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What is a Medical Records Release Authorisation Form?

The Medical Records Release Authorization Form is a crucial document in the U.S. healthcare system, designed to protect patient privacy while facilitating necessary information sharing. This form is required under HIPAA regulations whenever protected health information needs to be shared with third parties outside of treatment, payment, or healthcare operations purposes. Healthcare providers must obtain this signed authorization before releasing any patient records, and the form must include specific elements such as a description of the information to be disclosed, the purpose of the disclosure, the expiration date or event, and the patient's right to revoke the authorization. The document serves as both a legal safeguard and a standardized process for managing sensitive medical information transfers across healthcare settings.

What sections should be included in a Medical Records Release Authorisation Form?

1. Patient Information: Complete identifying information of the patient including full name, date of birth, address, phone number, and medical record number if applicable

2. Healthcare Provider Information: Details of the healthcare provider/facility authorized to release the records, including name, address, phone and fax numbers

3. Recipient Information: Complete details of the person or entity authorized to receive the medical records

4. Information to be Released: Specific description of the health information authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Statement of the reason for requesting the release of medical records

6. Duration of Authorization: Specific time period for which the authorization is valid

7. Rights Statement: Clear explanation of the patient's rights regarding the authorization, including right to revoke and any limitations

8. Signatures and Date: Space for patient or legal representative signature, date, and relationship to patient if not self

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

1. Sensitive Information Authorization: Additional specific authorization for release of sensitive information such as HIV/AIDS, mental health, or genetic testing records - required when such records may be included

2. Substance Abuse Records: Special authorization section compliant with 42 CFR Part 2 for substance abuse treatment records - needed when applicable

3. Electronic Records Format: Specification of electronic format for records delivery - included when electronic delivery is an option

4. Re-disclosure Notice: Additional warning about potential re-disclosure of information - used when sending records to non-healthcare entities

5. Payment Authorization: Authorization for any fees associated with records release - included when fees may be charged

6. Emergency Contact: Additional contact information for urgent communications - optional for complex medical records releases

What schedules should be included in a Medical Records Release Authorisation Form?

1. Schedule A - Types of Medical Records: Detailed checklist of specific types of medical records that can be released

2. Schedule B - State-Specific Requirements: Additional requirements or notifications required by specific state laws

3. Schedule C - Fee Schedule: Breakdown of any applicable fees for medical records release

4. Appendix 1 - Glossary: Definitions of medical and legal terms used in the authorization form

5. Appendix 2 - Patient Rights Summary: Detailed explanation of patient rights regarding medical records and privacy

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
Relevant legal definitions




















Clauses

















Relevant Industries

Healthcare

Insurance

Legal Services

Healthcare Technology

Pharmaceutical

Medical Research

Education (Medical Institutions)

Government Healthcare

Long-term Care

Occupational Health

Relevant Teams

Medical Records

Compliance

Legal

Patient Services

Health Information Management

Privacy and Security

Operations

Risk Management

Clinical Administration

Quality Assurance

Relevant Roles

Medical Records Administrator

Healthcare Privacy Officer

Compliance Officer

Medical Office Manager

Healthcare Administrator

Legal Counsel

Medical Secretary

Patient Services Coordinator

Health Information Manager

Practice Manager

Clinical Director

Risk Management Officer

Medical Records Clerk

HIPAA Privacy Officer

Healthcare Operations Manager

Industries







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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