Medical Records Release Form

A consent form for authorizing the release of medical records from a provider to a designated recipient for a specified date range.

Authorization Details

• Authorization Date
  Date you are signing this authorization.
• Patient Full Name
  Name of the patient whose records will be released.
• Patient Date of Birth
  Used to verify the patient's identity.
• Medical Record Number
  Optional identifier if your provider uses one.

Recipient Information

• Recipient Name
  Person or organization authorized to receive the records.
• Recipient Organization
  Optional organization, clinic, law firm, insurer, or employer name.
• Recipient Relationship / Role
  Select the recipient's role to support proper routing and disclosure review.
• Preferred Delivery Method
  How the records should be sent to the recipient.
• Recipient Contact Details
  Provide the fax number, mailing address, secure email, or other delivery details needed for release.

Records Requested

• Types of Records to Release
  Select one or more record categories to disclose.
• Other Record Types
  Describe any additional records not listed above.
• Records From
  Start date for the records to be released.
• Records Through
  End date for the records to be released.
• Purpose of Release
  Briefly state why the records are being released. This supports minimum-necessary disclosure.

Sensitive Information Consent

• Does this authorization include sensitive records?
  Select yes if the release includes mental health, substance use disorder, HIV/STI, genetic, or reproductive health records, if applicable under law and policy.
• Sensitive Record Categories
  Select any sensitive categories included in this authorization.
• Sensitive Records Details
  Provide any additional limits or instructions for sensitive records.

Consent and Signature

• Consent Acknowledgement
  I authorize the release of the records described above to the designated recipient for the stated purpose and date range. I understand this authorization may be revoked in writing, except to the extent action has already been taken based on it.
• Authorization Expiration Date
  Optional date when this authorization expires if earlier than the default policy expiration.
• Signature
  Patient or authorized representative signature.
• Signer Name
  Printed name of the person signing this authorization.
• Signer Relationship to Patient
  Select the signer's relationship if the patient is not signing personally.