A Patient Release Form is a one of the many types of Release Forms available on our website. A Release Form is used prior to a procedure or activity to release an institution or company from any legal liabilities or claims in the future. A Patient Release Form is one used for medical purposes by medical care facilities.

Patient Release Forms are also called Medical Release Forms. They are filled out prior to releasing a patient’s protected health information, releasing a patient’s photo or testimonial, or certifying an employee to return to work. The medical community has a lot of responsibilities. Aside from ensuring the health and welfare of the people, they are also tasked to protect their privacy.

Patient Information Release Form

Dental Patient Information Release Form

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Patient Authorization Information Release Form

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Size: 15 KB

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Patient Disclose Protected Health Information Form

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What is a Patient Release Form?

A Patient Release Form is used by many medical care facilities to protect themselves from any legal claims and  liabilities in the future. These forms have to be filled out before a medical care facility can release a patient’s medical records and before they can release a patient’s photo or testimonial for marketing purposes. There are also Patient Release Forms used by physicians to certify that a patient is already fit enough to return to work. Aside from Patient Release Forms, we also have Lien Release Forms that are mostly used by construction companies once they have been paid for a construction project. A Lien Release Form indicates that the construction company has already been paid, thereby releasing all claims on the property.

Steps in Releasing Patient Information

  • Obtain the patient’s consent to the disclosure of his or her medical information by letting him or her fill out and sign one of our Sample Release Forms here.
  • Respect the patient’s decision to object the release of his or her medical information.
  • Determine circumstances wherein a patient’s information has to be disclosed even without his or her consent, such as matters of public safety. In the absence of the patient, if the hospital determines that the patient’s health and welfare supersedes the concern for his privacy, only those information that are directly relevant can be disclosed.

Patient Records Release Form

Patient Medical Records Release Form

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Size: 82 KB

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Dental Patient Records Release Form

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Size: 6 KB

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Patient Medical Release Form

Patient Medical Information Release Form

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Size: 33 KB

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Generic Patient Medical Release Form

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Size: 110 KB

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Patient First Medical Release Form

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Size: 100 KB

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Medical Records Release Forms

Medical Records Release Forms are a kind of Patient Release Form or Hospital Release Form filled out by patients who wish to have the hospital release their medical information for whatever purpose it may serve. There are various reasons why patients would need to have their medical information released, such as legal reasons or employment reasons. No matter the reason, it is important to understand that the use of Medical Records Release Forms is done in accordance with the privacy rule of the Health Insurance Portability and Accountability Act or HIPAA. This is why Medical Records Release Forms are also referred to as HIPAA Release Forms.

They may have many terms, but their purpose is only one: to protect the privacy of patients by preventing an unlawful or unauthorized disclosure of protected health information. The entities covered by this privacy rule include medical care facilities, health insurance companies, and any other third party business partner that deals with protected health information.

Information to be Included on Medical Records Release Forms

  • Personal information of the patient, who is also the releasor on the release form
  • Information about the medical care facility being provided with consent (name, address, contact details)
  • Information about the individual or entity that will be provided with the patient’s medical information (employer, another medical care facility, etc.)
  • Type of protected health information that should be disclosed
  • Validity of the Release Form or the number of days the hospital has to release the patient’s medical information
  • Purpose of the disclosure of information
  • Explicit statement of intent to provide consent for release of medical information
  • Statement that the patient can revoke his or her consent at any time in writing, given that he or she understands the implications of revocation of such consent
  • Patient’s signature, along with the date it is signed

Patient Photo Release Form

Sample Patient Photo Release Form

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Size: 24 KB

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Patient Photo Release Form Template

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Size: 7 KB

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Patient Photographic  Authorization Release Form

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Size: 9 KB

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Patient Release Form Template

Patient Testimonial Release Form

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Size: 28 KB

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Patient Information Medical Release Form

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Size: 50 KB

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Staff Instructions Patient Release Forms

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When do you Need a Medical Records Release Form?

  • A patient’s health information has to be disclosed to substantiate health insurance claims and other workers’ compensation claims, especially for those with either short term or long term disability.
  • A patient’s health information also has to be disclosed and forwarded over to a receiving medical care facility in the event of a transfer. This will ensure that the patient’s medical treatment will be continued.
  • Patient General Release Forms are also used when a patient wants to take legal action against negligence resulting to physical injury or medical malpractice. The patient’s health information is to be used to determine the settlement amount the defendant will have to pay to the claimant if he wins the case.
  • A patient’s health information could also be disclosed when requested by an employer, such as in the case of a Return to Work Release, which testifies that the patient has been duly examined physically and is deemed by the physician as fit to return to work.
  • A Medical Records Release Form can also be used for research purposes, such as researching for the prevention and treatment of certain diseases. Patient health information would have to be accessed for statistical analysis. You may also see our Emergency Release Forms to prepare for medical emergencies.

Patient Authorization Release Form

Patient Authorization  Disclosure Release Form

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Size: 232 KB

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Authorization Release Protected Health Form

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Size: 166 KB

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Patient Work Release Form

Patient return Work Release Form

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Size: 19 KB

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Sample Patient Work Release Form

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Size: 17 KB

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Guidelines for Releasing Information on the Condition of Patients

  • A medical care facility may disclose a patient’s general condition and location if the person requesting such information can identify the patient by his or her full name. This applies to patients who are admitted, in for a consultation only, or those in emergency services.
  • Clergy members may also request a patient’s information, but only limited to the patient’s name, location, general condition, and religion, although a patient does not need to disclose his or her religious affiliation to the hospital and the hospitals are also not required to ask about this. Clergy members can be provided with the aforementioned information even without providing the patient’s name.

The patient’s general condition may be disclosed under the two aforementioned conditions, but only one word is to be used to describe the patient’s general condition.

The patient may be in good condition, which means that the patient is conscious and comfortable. His condition may also be fair, which means that he is conscious but not comfortable. Another is if the patient is in serious condition, which means is really ill and his vital signs are unstable. The last condition is critical, which means that the patient’s vital signs are unstable and he is unconscious. Aside from the use of Patient Release Forms, you may also see our samples of Waiver Release Forms and Work Release Forms for other purposes.

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