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Run: Medical Records Release Form

A Medical Records Release Form for authorizing a provider to send specific records to a named recipient for a defined date range. Use it to capture consent, ...

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Authorization Details

Authorization Date (required)

Date you are signing this authorization.

Patient Full Name (required)

Name of the patient whose records will be released.

Patient Date of Birth (required)

Used to verify the patient's identity.

Medical Record Number

Optional identifier if your provider uses one.

Recipient Information

Recipient Name (required)

Person or organization authorized to receive the records.

Recipient Organization

Optional organization, clinic, law firm, insurer, or employer name.

Recipient Relationship / Role (required)

Select the recipient's role to support proper routing and disclosure review.

Preferred Delivery Method (required)

How the records should be sent to the recipient.

Recipient Contact Details (required)

Provide the fax number, mailing address, secure email, or other delivery details needed for release.

Records Requested

Types of Records to Release (required)

Select one or more record categories to disclose.

Other Record Types

Describe any additional records not listed above.

Records From (required)

Start date for the records to be released.

Records Through (required)

End date for the records to be released.

Purpose of Release (required)

Briefly state why the records are being released. This supports minimum-necessary disclosure.

Sensitive Information Consent

Does this authorization include sensitive records? (required)

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 (required)

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.

Yes No N/A

Authorization Expiration Date

Optional date when this authorization expires if earlier than the default policy expiration.

Signature (required)

Patient or authorized representative signature.

Signer Name (required)

Printed name of the person signing this authorization.

Signer Relationship to Patient (required)

Select the signer's relationship if the patient is not signing personally.

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Email (required)

Your name (optional)

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