FREE 9+ Medical Records Authorization Forms in PDF | MS Word | Excel

Medical records are considered as confidential and private which is why hospitals, clinics, medical insurance providers, and employment companies ensure that they mandate protocols and procedures to fully protect the data and information of their patients and clients. One of the known documents which are deemed useful and essential in lieu of data protection is a medical records release authorization form to be signed by the patient.

What Is a Medical Records Release Authorization Form?

Medical records release authorization forms are documents which are intended to be filled out and signed by patients or individuals who will need to disclose their medical information to a third party. Most often, the recipient or the third party who will be receiving the medical records would be the insurance company, employer, or the educational institution of the requestor where he will be participating in activities, events, and programs periodically

Medical Records Release Authorization Form Sample

Patient Medical Record Release Authorization Form

Types of Medical Records Release Authorization Forms

Fertility Center Medical Records Release Authorization Form – There are four sections in this type of medical records release authorization form. The first section is allotted for the patient and his spouse’s name, date of birth, and insurance number while the second section is for specifying the types of data or records that the fertility center will be releasing. The last two sections, on the other hand, are for the acknowledgment of the patient and the signatures of the involved parties such as the patient himself, his spouse, the person who is processing the records, and the fertility center’s manager whose job designation is to review the records as well as the validity of the authorization.

Fertility Center Medical Records Release Authorization Form

General Medical Records Release and Disclosure Authorization Form – This form can be used for releasing both general medical records and any protected health information of a patient. The information which will have to be stated in the form by the patient or the requesting party would include the patient’s details and social security number, the range of records to be disclosed, the method of sending the medical records to the recipient, and the reason for the distribution of the records.

General Medical Records Release and Disclosure Authorization Form

HIPPA Medical Record Release Authorization Form – This is the type of form to use if the medical records are to be acquired and be used by the patient himself, and will not be distributed or be sent to third parties. In the form, the patient must disclose his general information along with the purpose of the record release, the types of documents and information needed to be included in the release, as well as his signature to complete the authorization.

HIPPA Medical Records Release Authorization Form

Medical Records Release Authorization Form FAQs

Can another person file a medical records release authorization form on behalf of a patient?

Yes, another person can file the form but he should be able to supply sufficient proof of his relationship with the patient as well as his eligibility in executing requests on behalf of the patient’s absence. Some of the documents that the requesting person can provide along with the authorization form would be a letter of representation, a signed medical power of attorney form, as well as legal identification cards to prove his identity.

What are the methods of distributing or acquiring medical records?

There are two methods which can be offered to the requesting party. The first method is by physically getting the medical records which had been printed and compiled by the medical institution. On the other hand, the second method is by sending the medical records to the electronic mailing addresses of the recipient and the requesting party of the authorization. However, the disadvantage of the second method is that there can be a security concern in lieu of protecting the records of the patient from being shared to unauthorized third parties. This is the reason why medical institutions who provide electronic distribution of the form incorporate passwords and codes to limit the number of minutes the receiving party can view and access the form.

Medical Records Copy Release Authorization Form

Medical Records Third Party Release Authorization Form

Medical Release Records Authorization Form

Medical Copy Records Authorization Form

Essential Sections of a Medical Records Release Authorization Form

Below are some of the basic yet essential sections of medical records release authorization forms:

The information of the requesting party

The requesting party’s legal name, personal phone number, date of birth, and other identification numbers will be some of the information to disclose in this section of the form.

The types of medical information or records to be requested

There can be different ranges of medical information and health records that a clinic or medical institution keep to ensure accurate records and history reports of their patients. This is why it is important that the requesting party will indicate the type of information that he would like the medical institution to release and disclose to the receiving party. The information can include details or records of accidents where the requesting party was involved in or even the drug usage history of the requesting party.

The name and details of the recipient or the receiving party

In this part of the form, the receiving party’s contact information and address must be stated. If there is an interpreter who will be viewing the medical records, then the interpreter’s basic information should also be disclosed in the form such as his name, telephone number, company affiliation, and identification number.

The payment for the medical records verification and acquisition process

Different medical institutions will have varying request policies in terms of gathering, copying, and distributing medical records. Some institutions do not require any type of fee or payment to be made by the authorizing party, while others do. And if so, the institution should have a payment information section in the form which will state the details of the payments to be provided by the authorizing party in order for the institution to execute the request and prepare the documents.

And lastly, the form should have an authorization statement which must clearly indicate the approval of the requesting party in lieu of the disclosure and distribution of his medical records to the party whom he is authorizing. Below the statement should be the signature area for the name, signature, and the date when the authorization was signed by the requesting or authorizing party.