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.
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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
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
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
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
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