When an individual wishes to use and release certain information to a third party, he is required to complete and sign a Release Form. This document will release the company that was the previous holder of the data from any responsibility and will hold the current company responsible in the event of any future damage incurred while using the information.

Release Forms are mostly used in the industry of film-making. However, it also serves an important purpose in the medical industry which uses Medical and Patient Release Forms. With the aid of the form, the information relating to the patient’s health issues and history will be given to the physician for examination.

Patient Release Information Forms

Patient Health Information Release Form

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Size: 33 KB

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Free Consent Release of Information Form

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Size: 675 KB

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HIPAA Patient Release Forms

HIPAA Privacy Authorization Form

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Size: 65 KB

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HIPAA Patient Complaint Release Form

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Size: 14 KB

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Sample HIPAA Privacy Authorization Form

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Dental Patient Release Forms

Free Dental Patient Record Release Form

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Size: 222 KB

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Dental Patient Records Release Form

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Dental Patient Authorization Release Record Form

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Importance of Patient Release Forms

There is certain information stated on a Patient’s Medical Record which is considered sensitive and should be kept private. But to have a thorough examination of the patient’s condition, the doctors and physicians will ask for every detail about the Medical History of the patient. To acquire the patient’s records, the medical personnel will have to submit a Release Form to the previous medical center where the patient was admitted.

This form is for granting authority to a specific medical agency to use the information in curing the patient’s illness. It is a valuable document in assuring that there is enough privacy observed with regards to handling the information and the medical diagnoses of the patient. A Patient Release Form may also be used when there is a minor or a child under the care of a guardian in the event that the parents are not available. This is to ensure that there is someone to look after the child in emergency cases.

Filling Out a Patient Release Form

Here are the specific instructions if you need to release and give a patient’s Medical History and Records to a third party:

Step 1: Complete the Patient’s Information which includes his name, his date of birth, a set of emergency contact numbers, and the patient’s mailing addresses.

Step 2: State the location of the Medical Center or the Facility where you need the records to be delivered. In the case of having two or more facilities, you, as a guardian or requestor, will have to complete duplicate copies of the form and submit those individually to each center.

Step 3: Indicate the Physician’s Information. This should include the full name of the physician, with his professional title, his contact information, fax number, and his address.

Step 4: Write the type of information to be shared. The specifics and limitations of the patient’s information should be clearly indicated in this area. The doctor or physician may require an abstract or he may ask for the complete details of the patient’s medical records, but it will be up to you as a guardian, to choose whether to release and grant him authority or not.

Step 5: Clarify the duration. This refers to the validity of the authorization. Most Release Forms are valid for a year unless the guardian will state a specific date of revoking the permission.

Step 6: Check the fees. Some Patient Release Forms contain boxes and placeholders for the fees accompanied in the releasing of medical records and information, so be sure to check the appropriate box for your payment.

Step 7: Affix your signature. Since you are the guardian of a patient, you will have to indicate beside your signature what the relationship is between you and the patient.

Step 8: Close the document with a date. It is very important to write the date of the day you signed the form since the one-year validity will be based on this date.

Doctor Patient Release Form

Doctor Patient Confidentially Release Form

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Hospital Patient Release Form

Patient Information Medical Release Form

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Size: 50 KB

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University Hospital Patient Release Form

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Emergency Patient Release Form

Minor Emergency Release Form

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Emergency Medical Release Form

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Medical Information Release Authorization in PDF

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Patient Photo Release Form

Patient Photo Release Consent Form

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Size: 7 KB

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Patient Photo Release Form in PDF

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Free Patient Photo Release Form

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Patient Release Form Varieties

Patient Health Information Release Form – This is the commonly used document which is needed to grant an authorization for the previous medical agency to release the health information of the patient. A Consent Release of Information Form may also be used as an alternative for general medical purposes.

HIPAA Privacy Authorization Form – The acronym stands for “Health Insurance Portability and Accountability Act”. This form is a necessity whenever the information that is stated on the Patient’s Record is under a confidential category, such as the patient’s HIV/AIDs and mental statuses. Before a guardian or a relative can submit the Release document, he needs to complete a Durable Power of Attorney for Healthcare Form to legalize his capability of requesting the patient’s private medical records.

HIPAA Patient Complaint Release Form – When a patient or a guardian witness a violation with the use of the released information, they may file this Complaint Form to the Office of Civil Rights. The complaint will be submitted to an HIPAA investigator and if proven true, the violator will face damages and penalties for his actions.

Dental Patient Record Release Form – This form is for requesting the release of the dental records of a patient, including his diagnoses, the dentist’s notes, the test images, and the billing fees of the dental examinations.

Doctor-Patient Confidentially Release Form – Similar to the HIPAA Privacy Authorization Form, this document is also used for cases of protecting the sensitive information in a patient’s medical records. There is a law that requires this form which states the inability of the doctor to use the patient’s information during court trials and sessions.

University Hospital Patient Release Form -This is the type of form to be used by a former student of a university in disclosing his medical information to a third party. To fully legalize the release, the University may require a parent’s approval and signature in the form.

Minor Emergency Release Form – This is form is needed to be completed by parents as a preventive preparation for emergencies. The form will state that the parents will authorize an immediate release of their child’s medical information whenever it is needed by the medical center or by the physician.

Medical Information Release Authorization Form – This authorization’s coverage ranges from the patient’s dental information to his laboratory test results. This form includes all the information on the patient’s medical record and is commonly used when patients move from one medical center to another. A Healthcare Provider may also require their members to submit this form to make a record in their data systems.

Patient Photo Release Consent Form – This form is often used for patients who are required to submit a dental, X-ray and other laboratory test results. The Consent Form will state that the patient will authorize the physician to use his digital photographs for specific purposes, such as comparing the tests results or maybe using the images to build a health-related banner.

Patient Testimonial Release Form – Compared to the aforementioned Photo Release Form, this Testimonial Release is for granting a permission to an individual to use the patient’s medical videos, testimonies, audio, and images.

Patient Records Release Form

Authorization Medical Records Release Form

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Size: 237 KB

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Dental Patient Records Release Form

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Size: 236 KB

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Authorization Medical Information Records Release Form

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Size: 187 KB

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Patient Testimonial Release Form

Patient Testimonial Release Form in PDF

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Size: 28 KB

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Patient Testimonial Release Consent Form

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What is an HIPAA?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a legislative order in the United States that contains the rights of an individual for having a secured and protected medical records and data. There are five sections of the Act, which are:

Section I. States the obligation of any health care provider to provide a coverage for their members even through an event of a job resignation, and in having specified health conditions and diseases.

Section II. This section covers the country’s standards for healthcare transactions online. The HIPAA Law demands the healthcare agencies in taking advanced security measures to safeguard their member’s medical records.

Section III. The provisions for added taxes and the important guidelines healthcare institutes should follow are stated under this section of the law.

Section IV. This section focuses on the ability of any member to continue his healthcare coverage. It also states the reforms for health insurances.

Section V. Those who are former US citizens whose citizenship was revoked due to their failure in complying with the State’s regulations. They may still be a member of a healthcare provider, however, there are certain conditions and provisions that are to be observed for their transactions.

There are two important forms which are associated with this legislative act and those are the HIPAA Privacy Authorization Forms and the HIPAA Patient Complaint Release Forms. Both documents focus on protecting the data of the US citizens’ medical records.

Quick Tips for Patient Release Forms

If you are going to fill out a Release Form for the first time, here are the things that you should remember before you submit the final form to the authorized personnel:

Always identify who to send your medical form to. If he is a physician, pediatrician, or a nurse, it is mandatory that you know his full identification including his job title and mailing details.

Clarify the records that you want to release. This will be easy for a patient, however, if you are a relative or a guardian, you need to ask the physician who requested the records unto what specific information that he will need for the patient.

Remember who is obligated. The amount of data that you will be releasing will be under your obligation and the requestors’. This is because you are the one who requested the types of information to be released, and the requestor is the one who is using the data you are authorizing them to use.

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