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Free Medical Records Release Template
A HIPAA-compliant authorization form for U.S. patients who need to transfer medical records between providers, insurers, or attorneys. Use this free American medical records release template — fill in your details, download a professional PDF in minutes.
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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Hipaa-compliant Authorization — 45 C.F.R. §§ 164.501-164.534 (§ 164.508)
PATIENT INFORMATION
| PATIENT FULL NAME | Sarah Elizabeth Mitchell |
| DATE OF BIRTH | April 22, 1985 |
| SSN (LAST 4 DIGITS) | XXX-XX-4567 |
| ADDRESS | 789 Elm Street, Denver, CO 80203 |
| PHONE | (303) 555-0142 |
| sarah.mitchell@email.com |
HEALTHCARE PROVIDER (RELEASE FROM)
| PROVIDER / FACILITY | Denver General Hospital |
| ADDRESS | 456 Medical Center Blvd, Denver, CO 80204 |
| PHONE | (303) 555-0200 |
| FAX | (303) 555-0201 |
| DEPARTMENT | Cardiology |
RELEASE TO (RECIPIENT)
| RECIPIENT NAME / FACILITY | Dr. Jane Smith, Mountain View Medical Group |
| ADDRESS | 1200 Health Way, Boulder, CO 80301 |
| PHONE | (303) 555-0300 |
| FAX | (303) 555-0301 |
| PURPOSE OF RELEASE | Continuing medical care and treatment |
RECORDS REQUESTED
| DATE RANGE | January 1, 2024 through December 31, 2024 |
| RECORDS INCLUDED | Medical History and Physical Exams, Laboratory Results, Imaging / Radiology, Prescriptions / Medications |
| RECORDS EXCLUDED | Mental Health Records, Substance Abuse Records |
| SPECIFIC CONDITIONS / TREATMENTS | Cardiac stress test results and echocardiogram reports from March 2024 |
I, Sarah Elizabeth Mitchell, hereby authorize Denver General Hospital to release the above-described protected health information to Dr. Jane Smith, Mountain View Medical Group for the purpose of continuing medical care and treatment. This authorization contains each of the core elements and statements required by the HIPAA Privacy Rule, 45 C.F.R. § 164.508(c): a specific description of the information to be used or disclosed, the name of the person(s) authorized to make the disclosure, the name of the person(s) to whom the disclosure is made, a description of the purpose, an expiration date, and the signature of the individual and date.
I understand that:
• Right to Revoke: I have the right to revoke this authorization in writing at any time under 45 C.F.R. § 164.508(b)(5), except to the extent that action has already been taken in reliance on it. A written revocation must be sent to the provider’s Privacy Officer.
• Conditioning of Treatment: Under 45 C.F.R. § 164.508(b)(4), treatment, payment, enrollment in a health plan, or eligibility for benefits may not be conditioned on signing this authorization, except in limited circumstances identified in the Rule.
• Re-disclosure Risk: Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy regulations in 45 C.F.R. Part 164.
• Expiration: This authorization expires one (1) year from the date of signature unless a different expiration date or event is specified above.
• Right to Copy: I am entitled to receive a copy of this authorization and, under 45 C.F.R. § 164.524, a copy of my designated record set, generally within 30 days of request.
• Information Blocking / 21st Century Cures Act: The Provider is obligated under the 21st Century Cures Act, 42 U.S.C. § 300jj et seq., and the ONC Information Blocking Rule, 45 C.F.R. Part 171, to make electronic health information available without unreasonable delay.
• Special Categories: Where applicable, this authorization is also intended to comply with the Genetic Information Nondiscrimination Act (GINA), 42 U.S.C. §§ 2000ff et seq.; FERPA, 20 U.S.C. § 1232g (for school-based health records); and state medical-records statutes, including Cal. Health and Safety Code §§ 123100 et seq., N.Y. Pub. Health Law § 18, Tex. Health and Safety Code §§ 181.001 et seq., and Fla. Stat. § 456.057.
I understand that:
• Right to Revoke: I have the right to revoke this authorization in writing at any time under 45 C.F.R. § 164.508(b)(5), except to the extent that action has already been taken in reliance on it. A written revocation must be sent to the provider’s Privacy Officer.
• Conditioning of Treatment: Under 45 C.F.R. § 164.508(b)(4), treatment, payment, enrollment in a health plan, or eligibility for benefits may not be conditioned on signing this authorization, except in limited circumstances identified in the Rule.
• Re-disclosure Risk: Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the federal privacy regulations in 45 C.F.R. Part 164.
• Expiration: This authorization expires one (1) year from the date of signature unless a different expiration date or event is specified above.
• Right to Copy: I am entitled to receive a copy of this authorization and, under 45 C.F.R. § 164.524, a copy of my designated record set, generally within 30 days of request.
• Information Blocking / 21st Century Cures Act: The Provider is obligated under the 21st Century Cures Act, 42 U.S.C. § 300jj et seq., and the ONC Information Blocking Rule, 45 C.F.R. Part 171, to make electronic health information available without unreasonable delay.
• Special Categories: Where applicable, this authorization is also intended to comply with the Genetic Information Nondiscrimination Act (GINA), 42 U.S.C. §§ 2000ff et seq.; FERPA, 20 U.S.C. § 1232g (for school-based health records); and state medical-records statutes, including Cal. Health and Safety Code §§ 123100 et seq., N.Y. Pub. Health Law § 18, Tex. Health and Safety Code §§ 181.001 et seq., and Fla. Stat. § 456.057.
PATIENT / AUTHORIZED REPRESENTATIVE
Sarah Elizabeth Mitchell
Date: ____________________
WITNESS
Date: ____________________
Available as a print-ready PDF or an editable Microsoft Word (.docx) file.
What Is a Medical Records Release Form?
A medical records release form, also called an authorization to disclose protected health information (PHI), is a signed document used throughout the United States that gives a healthcare provider permission to share your medical records with a specified third party. Under HIPAA — the Health Insurance Portability and Accountability Act, a uniquely American federal law — covered entities such as U.S. hospitals, clinics, and health insurers generally cannot release your health information without your written authorization.
Common reasons for using this American form include transferring records to a new doctor, providing documentation for a U.S. insurance claim, sharing records with an attorney for a personal injury case, or obtaining copies of your own medical history for personal records. The authorization must clearly identify who is releasing the records, who will receive them, what types of information are covered, and how long the authorization remains valid.
A properly completed U.S. medical records release protects both the patient and the provider. It creates a clear, auditable paper trail showing that the disclosure was authorized, which specific information was requested, and for what purpose. This is especially important when sensitive information such as mental health records, substance abuse treatment, or HIV status is involved, as these categories often have additional legal protections at both the federal and American state level.
What's Covered in This Template
Doxuno's medical records release template includes all elements required by HIPAA for a valid authorization, plus additional fields for state-specific requirements and sensitive record categories.
Patient Identification
Releasing Party Details
Receiving Party Details
Types of Records
Purpose of Disclosure
Date Range of Records
Expiration Date
Right to Revoke
Re-disclosure Warning
Legal Representative
Sensitive Records Notice
Patient Signature & Date
How to Create Your Medical Records Release
Doxuno's template guides you through each required field. The form follows HIPAA's authorization requirements so you do not miss any essential elements.
- 1
Enter the patient's information
Provide the patient's full legal name, date of birth, address, phone number, and medical record number if available. If a legal representative is authorizing the release, include their name and relationship to the patient.
- 2
Identify the releasing and receiving parties
Specify which healthcare provider, hospital, or facility currently holds the records. Then enter the name and address of the person or organization that will receive the records, such as a new doctor, insurance company, or attorney.
- 3
Select the types of records to release
Choose which categories of medical information you are authorizing for release. You can authorize all records or limit the release to specific types such as lab results, imaging, prescriptions, or surgical notes.
- 4
State the purpose and set the expiration
Describe why the records are being released (continuation of care, insurance claim, legal matter, or personal use) and set an expiration date for the authorization. One year is a common choice, though you can set any reasonable period.
- 5
Review and download
Review the completed authorization in the live preview to confirm all details are correct, then download it as a professional PDF. The patient or their legal representative signs the form before submitting it to the healthcare provider.
Why Doxuno documents are different
Four things that make our templates more thorough than AI-generated drafts and more current than static template libraries.
Always current
Always current with the law
Templates carrying statute references are continuously updated as the law changes. Your document always reflects the current legal framework.
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Print-ready PDF
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Editable Word (.docx)
Continue editing in Word after download. Add custom clauses, reuse the template for similar agreements, or share with a colleague for collaborative review.
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Legal Considerations for Medical Records Releases
While this template is designed to meet HIPAA's federal requirements, individual states may impose additional rules. Understanding these nuances will help ensure your authorization is accepted by any provider.
This template is provided for informational purposes and does not constitute legal advice. For sensitive records (mental health, substance abuse, HIV), or if you are releasing records for litigation purposes, consult a licensed attorney or your healthcare provider's privacy officer.
Reviewed by legal professionals. The content on this page and the template fields have been reviewed by licensed attorneys and healthcare compliance specialists in the United States to ensure HIPAA compliance for standard medical records authorization scenarios.
HIPAA Authorization Requirements
Under the HIPAA Privacy Rule (45 CFR 164.508), a valid authorization must contain six core elements: a description of the information, who is authorized to make the disclosure, who will receive it, the purpose, an expiration date or event, and the individual's signature and date. Missing any of these elements can render the authorization invalid, and the provider may refuse to release records.
State-Specific Requirements
Many U.S. states impose requirements beyond HIPAA. For example, New York requires specific language about mental health records under the NY Mental Hygiene Law, Texas requires authorizations to be on a state-approved form for certain disclosures, and California has additional American state-law protections for HIV-related information. Always check your U.S. state's requirements, especially for sensitive record categories.
42 CFR Part 2 and Substance Abuse Records
Substance abuse treatment records maintained by federally assisted U.S. programs are subject to 42 CFR Part 2, a federal American regulation that imposes stricter consent requirements than standard HIPAA rules. A general medical records release may not be sufficient to authorize the release of substance abuse treatment records in the United States. A separate, specific consent form may be required.
Minor Patients and Incapacitated Adults
For patients under 18, a parent or legal guardian must sign the authorization in most U.S. states. However, some American states grant minors the right to consent to certain types of treatment (such as reproductive health or substance abuse treatment), and in those cases the minor may need to authorize the release themselves. For incapacitated adults in the United States, a court-appointed guardian, healthcare proxy, or power of attorney holder may sign.
Frequently Asked Questions
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