Authorization to Release Medical Records Template
Patients or authorized representatives use this form to direct a healthcare provider to release specified medical records to a named recipient for a stated purpose and period.
When to use it
- Sending records to a new healthcare provider
- Sharing records with an insurance company
- Authorizing a family member or caregiver to receive records
- Releasing records for a personal or administrative purpose
What it asks
- Your full name
- Your email address
- Your phone number
- Patient’s full legal name
- Patient’s date of birth
- Healthcare provider or facility holding the records
- Which records should be released?
- Recipient’s name and organization
- Recipient’s email address for secure delivery
- Purpose of the release
- When should this authorization expire?
- If you are not the patient, your relationship or authority to sign
- I authorize the provider or facility named above to release the specified records to the recipient for the stated purpose, until the expiration date.
- Signature name
- Date signed
Why it should be encrypted
The form includes identifying details and information about a patient's care and records. Only the patient or authorized representative and the intended recipient should be able to read the answers.
Tips
- Specify which records and date range the provider should release.
- Confirm the recipient's organization and secure delivery address before sending.
- Set a clear expiration date and make sure the signer has authority to authorize the release.