Release Of Information Form
Meet your privacy obligations under HIPAA with this authorization to release medical information form. Always stay on top of your patient's health concerns, and safeguard their details with ease.
Fact Checked by Ericka Pingol.
What Is A Release Of Information Form
A is a special document your patients or their legal representative can use to legally authorize you to disclose their medical information to another person or organization. This is commonly required when patients transfer hospitals or medical providers or need to disclose medical information to their insurance companies, school, or employers.
Your patient’s medical information is protected under HIPAA and you therefore cannot share this information with other organizations without prior authorization from your patient or their legal representative.
This form should include specific details such as the person or organization being authorized, the person or organization being sent the information, the nature of the information being shared, the reason for the disclosure of information, and important statements that the patient needs to understand before they sign. These statements are crucial to ensure your patient does not feel they need to disclose information in exchange for treatment, and so they understand their right to revoke their authorization- as well as the irreversibility of any disclosures that occur as a result of their initial authorization.
Printable Release Of Information Form
Download these templates for Medical Release of Information to improve your paperless intake process and HIPAA compliance.
How To Use This Template For Release Of Information Form
It is important that you understand how this form is used, and the legal responsibility you have under HIPAA to abide by the terms of the authorization as set out in this form. Here are five simple steps to follow to use this form in your practice.
Step One: Download the template
The first step is to download a copy of this template. You can download the free PDF version of this template from the link on this page.
Step Two: Have your patient fill out the applicable sections
It’s a good idea to run through the different sections with your patient to ensure they understand the authorization. Your patient should then fill out their details, the details of the authorized and receiving organizations (if you haven’t done so for them already), and the expiration section.
Step Three: Patient or their representative to read and sign the authorization
It’s important your patient or their representative understand their rights regarding the disclosure of their medical information. As such, they should read and understand the Statement of Rights section before signing in the appropriate section. For patients requesting disclosure of their own information, they can sign under Patient Signature. Parents, guardians, or legal representatives of the patient, can sign under the Legal Representative section. Make sure to check your state or country’s laws on disclosure of a minor’s medical information, as you may need the minor’s signature as well as their legal guardian’s.
Step Four: Once authorized, provide a copy for your patient and complete the specified information disclosure securely
Once the form is complete and submitted to you, provide a copy to your patient and complete the authorization they have requested in the form. These tasks involve the transfer of patient health information, and so should be completed securely. We recommend secure electronic transfer rather than physical postage as you can utilize digital encryption and ensure the form won’t get lost in the post!
Step Five: Complete any expiration of authorization tasks in a timely manner
Finally, you may be obligated to update your records or permanently delete patient information prior to the date stated in the authorization form, or upon written request from the patient or their representative. It’s best to remain diligent on files stored locally or shared from another institution, as if the authorization is revoked, you can no longer disclose that information and will need to be able to prove how you have complied with the revocation if requested.
Release Of Information Example (Sample)
This form has a few different sections and requirements, and it’s important to understand the difference between the named people/organizations in this template. To help you complete this template yourself, we have made a fictional example release of information form for you to read below.
Download this Release Of Information Example (Sample) here:
Who Can Use this Printable Medical Release Form (PDF)?
This form is designed for use by any individual who wishes to have their medical information shared with another person or organization. There are many reasons someone might want their information sent to another organization, including for continuing medical treatment, changing providers, legal proceedings, insurance claims, employment applications, or providing to their school or university.
Release of information forms is commonly used by hospitals or medical providers in order to facilitate the care of their patients by allowing them to access their patient’s past medical records which may be stored at a different provider. Having the authorization of their patient to disclose information can allow a medical provider to gain a fuller picture of their medical history, and help the continuity of care for the patient across different providers. Professionals who may find this form useful to provide to their patients include
- Medical specialists
- Physicians
- Nurses and nurse practitioners
- Allied health professionals
- Medical practice managers or administrators
- Insurance companies, employers, or schools require proof of medical history on their clients.
This list is by no means exhaustive, as there are many situations in which someone may need to have their medical information released.
Why Is This Form Useful For Clinicians
Keep your records electronic
This medical release form is an interactive PDF meaning you can keep this record completely digital and reduce the risk of a paper copy falling into the wrong hands.
Improve collaboration with other providers
Having a procedure in place for the sharing of information with other providers means you can collaborate more efficiently, and spend less time with the administration of the information release and more time tending to your patients.
Standardize your information release process
Standardizing the process of disclosing patient information is key to ensuring every medical release request is handled correctly and in a timely manner.
Why Use Carepatron For Release Of Information Forms?
As we mentioned earlier, transferring data digitally means you benefit from digital encryption and user authorization. Carepatron is a great way to securely store, access, and transfer your patients’ sensitive information digitally, and you can find this release of information form, along with many other useful templates, right from within Carepatron.
Along with HIPAA-compliant security for your patient data storage and transfer, Carepatron also offers you state-of-the-art practice management software with all the perks you need to take your practice’s efficiency to the next level. Manage your client list, appointments, coding, billing, and payments all from within Carepatron. Reduce no-shows and maximize productivity with automated SMS or email appointment reminders, and securely access your patient information wherever you need from Carepatron’s intuitive mobile or desktop platforms.
Commonly asked questions
Release of information means the authorized person or organization can legally disclose the specific patient information, as indicated in the form, to the receiving person or organization, also specified in the form. The release of information is a specific process with a designated destination, purpose, and time-period. It does not mean that the authorized organization has no obligation to keep this information secure!
The patient or their representative can legally revoke their authorization in writing to the previously authorized agency. It’s important that they understand, however, that any disclosures already made under their initial permission cannot be undone.
This form includes a space for the patient to sign if they are authorizing the release of their own information, or for their representative to sign if they are a minor or incapable of signing themselves. The representative signature section also includes an optional space for the minor to sign, which is required in some situations for the release of a minor’s information.
