Authorization to release protected health information form

Updated August 04, 2022

The medical record information release (HIPAA) form allows a patient to give authorization to a 3rd party and access their health records. The release also allows the added option for healthcare providers to share information. A medical release form can be revoked or reassigned at any time by the patient.

Laws – 45 C.F.R. Part 160 and 45 C.F.R. Part 164

What does HIPAA stand for?

Health Insurance Portability and Accountability Act

By State

• Alabama
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By Type (4)

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How to Get Medical Records

Accessing and obtaining your medical records is a requirement under 45 CFR 164.524 which requires that any request made to access or transfer medical records must be completed within 30 days, or a letter must be sent to the requestor stating why the records are delayed.

Step 1 – Request the Medical Records

To legally request medical records, under 45 CFR 164.524(b)(1), the entity holding the records may require that the request is made in writing. Therefore, use the Standard Form and use the “How to Write” section of this page to enter the specific fields required to complete.

The 4 sections are:

• Releasor and Recipient – Who has the medical records, and to who will they be sending them?
• Time Period – What dates are authorized for release?
• Record Types – Should only specific records be released about certain medical conditions, or should all the patient’s records be released?
• Expiration Date – Usually, a date is listed at which it expires for legal purposes.

Step 2 – Sending the Letter

When sending the letter to the medical facility it is best to request how the record should be sent; examples include, an electronic document (PDF, Word), USB Flash Drive, CD, etc. The medical facility may charge a fee for sending the records, although, they are prohibited from charging for processing the request.

Step 3 – Receiving the Medical Records

Modern medical facilities are typically aware that time is of the essence in regards to the records of an individual. Therefore, if the requested information is not received within 5 to 7 business days the requestor should call or ask to know the status of the transfer.

The medical facility has 30 days to release the requested medical records. If the initial 30-day period is not met they may extend for an additional 30 days only if they send a letter to the requestor stating why the transfer is delayed. Only one (1) extension period is allowed by law.

Getting Medical Records for Someone Else

Under 45 CFR § 164.502(g), an individual may obtain medical records on behalf of someone else. There are three (3) options:

Option 1 – Personal Representative

An individual, such as an attorney-in-fact (or “agent”) mentioned in a Medical Power of Attorney, commonly has powers to obtain medical records. In addition, for any person that has been appointed by a court to act as a caregiver or guardian, the judgment, order, or decree must be attached to the HIPAA release form.

Option 2 – Adult or Legal Guardian

An adult or legal guardian is legally authorized, under federal law, to obtain the medical records of a minor. If the medical records are for healthcare services that will be provided, the minor may be required to consent to such care based on State law.

Option 3 – Administrator of an Estate

An administrator, personal representative, executor, or another authorized person with the authority to act on the deceased person’s estate. Suppose, for any reason, the medical records of the deceased are requested. In that case, the administrator appointed in the Last Will and Testament or a court-appointed authority may be able to obtain the records.

Is There a Fee ($) to Release Medical Records?

Yes, but this depends on the medical office and the state it is located. Generally speaking, smaller offices do not require a fee for copying and transferring medical records. If a medical office does charge a fee, it cannot be more than the statutory limit (see table below):

State-by-State Maximum Limits ($)

Video

Sample

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HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

Date: [DATE]

I. THE PATIENT. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Patient’s Name: [PATIENT’S NAME]
Date of Birth:  [DATE OF BIRTH]
Social Security Number: [SSN]

II. AUTHORIZATION. I authorize [AUTHORIZED PARTY’S NAME] (“Authorized Party”) to use or disclose the following: (check one)

☐ – All of my medical-related information.
☐ – My medical information ONLY related to: [ENTER MEDICAL CONDITION]
☐ – My medical-related information from [DATE] to [DATE].
☐ – Other: [OTHER]

Hereinafter known as the “Medical Records.”

III. DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records to: (check one)

☐ – Any party that is approved by the Authorized Party.

☐ – ONLY the following party:

Name: [RECIPIENT’S NAME]
Address: [ADDRESS]
Phone: [PHONE] Fax: [FAX]
E-Mail: [E-MAIL]

IV. PURPOSE. The reason for this authorization is: (check one)

☐ – General Purpose. At my request (general).

☐ – To Receive Payment. To allow the Authorized Party to communicate with me for marketing purposes when they receive payment from a third party.

☐ – To Sell Medical Records. To allow the Authorized Party to sell my Medical Records. I understand that the Authorized Party will receive compensation for the disclosure of my Medical Records and will stop any future sales if I revoke this authorization.

☐ – Other: [OTHER]

V. TERMINATION. This authorization will terminate: (check one)

☐ – Upon sending a written revocation to the Authorization Party.
☐ – On the following date: [DATE]
☐ – Other: [OTHER]

VI. ACKNOWLEDGMENT OF RIGHTS.

I understand that I have the right to revoke this authorization, in writing and at any time, except where uses or disclosures have already been made based upon my original permission. I might not be able to revoke this authorization if its purpose was to obtain insurance.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that Medical Records and information used or disclosed with my permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create Medical Records for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.

Signature of Patient: __________________________ Date: ________________
Print Name: ________________________

(IF THE PATIENT IS UNABLE TO SIGN, USE THE SIGNATURE AREA BELOW)

The patient is unable to sign due to: (check one)

☐ – Being a Minor. Patient is [#] years old and a minor under state law.
☐ – Being Incapacitated. Patient is incapacitated due to: [DESCRIBE CONDITION]
☐ – Other: [OTHER]

Signature of Representative: __________________________ Date: ________________
Print Name: ________________________

Relationship to Patient: ☐ Parent ☐ Spouse ☐ Guardian ☐ Other: [OTHER]

ADDITIONAL CONSENT FOR CERTAIN CONDITIONS

I. SENSITIVE INFORMATION. This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.

(check one)

☐ – I consent to have the above information released.

☐ – I do not consent to have the above information released.

Signature of Patient: __________________________ Date: __________________
Print Name: ________________________

II. HIV/AIDS. This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.

(check one)

☐ – I consent to have the above information released.

☐ – I do not consent to have the above information released.

Signature of Patient: __________________________ Date: __________________
Print Name: ________________________

How to Write

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I. The Patient

(1) Preliminary Information. The date when this paperwork should be considered completed with information must be documented in the area preceding the First Article. Keep in mind this may not be after the signature date of the Patient or Patient Representative executing this consent since this paperwork must be complete before it is signed.

(2) Patient’s Name. The First Article of this authorization requires full identification of the Patient executing it. His or her entire legal name should be presented on the “Patient’s Name” line.

(3) Date Of Birth. In addition to his or her name, the “Date Of Birth” of the Patient must be submitted to the second space in Article I (“The Patient”).

(4) Social Security Number. Finally, in the spirit of further and clearly identifying the Patient issuing this consent, the “Social Security Number” of the concerned Patient should be documented in the final area of the First Article.

II. Authorization

(5) Authorized Party. This instrument shall require that the full name of the Entity the Patient authorizes to use or dispense his or her medical information (i.e. medical history, tests, current conditions etc.) is documented to supplement the language of Article II. Submit the full legal name of this Authorized Party to the blank space following the term “I Authorize…” Since this declaration statement must deliberately state the Patient’s intent, a choice must be made from one of the following items to define precisely what medical information is authorized for release.

Select Item 6 Or Select And Complete Item 7 Or Item 8 Or Item 9

(6) All Medical Related Information. If the Patient is allowing the Authorized Party to release any or all of his or her “Medical-Related Information” as needed, then the first checkbox statement in Article II should be marked for selection. Note, that this will exclude certain sensitive medical records (i.e. HIV/AIDs status) since this would require a specific release from the Patient.

(7) Specific Medical Information. If the Consenting Patient does not wish to authorize an indiscriminate release of all his or her medical information through this instrument of consent, he or she may limit the authorized release of medical information to only a specific topic or condition. For this effect, select the second checkbox statement from the Second Article. Additionally, this selection requires that the exact nature of the information the Patient authorizes for release is established on the blank space available. If more room is needed, it may be inserted directly to this statement or an attachment with a listing of the medical conditions or topics the Patient authorizes may be developed and affixed to this instrument.

(8) Range Of Approved Disclosure. The Patient may prefer to authorize the release all medical information accumulated only during a certain period of time. If so, then the third checkbox statement should be selected. This selection will require that the first and last date of the authorized release term is documented to the date-formatted areas.

(9) Other Disclosure. There may be “Other” circumstances or conditions the Patient wishes used in determining the nature of the medical information authorized for release that cannot be readily defined by the previous three options. If so, then the final checkbox (labeled as “Other”) should be selected and the blank space available should be supplied with the requirements needed for the Patient’s authorization to be given.

III Disclosure

Select Item 10 Or Select And Complete Item 11

(10) Any Approved Party. This release must target the appropriate Receiver of the Patient’s medical information. Therefore, locate the Third Article for review. If the Patient intends to allow the Authorized Party named in the previous article to determine who should be approved to receive the Patient’s medical information, then the first checkbox displayed in Article III should be marked. This selection will give the Authorized Party the consent needed to determine who may receive the Patient’s medical records, history, and information (as defined above).

(11) Specific Party. If the Patient intends to use this paperwork as authorization for the release of his or her medical information to a specific Party, select the second checkbox statement from Article III. Once done, utilize the spaces provided to dispense the legal Name of the Party that is the Authorized Recipient of the Patient’s medical information along with this Recipient’s complete address, Phone number, Fax number, and E-Mail address. This selection will limit the Authorized Party to release the Patient’s medical information only to the Recipient listed here.

IV. Purpose

Select Item 12 Or Select Item 13 Or Select Item 14 Or Select And Complete Item 15

(12) General Purpose. Article IV shall seek to establish why the Patient is authorizing the release of his or her medical information. If Patient consent is given for a “General Purpose” (as defined and as needed by the Authorized Party), then the first checkbox from Article IV should be selected.

(13) To Receive Payment. If the Patient’s medical information should be released so that the Authorized Party may receive payment and communicate with the Patient, then the second checkbox should be selected from the Fourth Article.

(14) To Sell Medical Records. If the Patient’s medical records require this release so that these records may be sold for profit by the Authorized Party, mark the third checkbox.

(15) Other. The Patient may use this paperwork to release his or her medical information for whatever legal reasons he or she deems appropriate such as those discussed by the previous three options. However, if none of the choices above can define the Patient’s purpose for such consent, then the “Other” checkbox should be selected. Additionally, a defined purpose for this release of his or her medical information should be presented on the blank space after the word “Other.”

V. Termination

Select Item 16 Or Select And Complete Item 17 Or Item 18

(16) Upon Written Revocation. The Patient should set a method for the authorization being delivered through this instrument to terminate naturally. If he or she prefers the consent being issued to exist until he or she revokes the Authorized Party’s ability to release his or her medical information, the first checkbox from Article V should be selected. Bear in mind, it will be expected (in many if not all cases) that such a revocation of authorization should be made in writing by the Patient and presented to all relevant Parties in order for it to be effective.

(17) Termination Date. The Patient can set a specific predetermined date that will prompt an automatic revocation of the authorization delivered through this document. To set this termination date, the second checkbox statement in Article V must be marked, the precise date of termination should be documented on the formatted lines provided.

(18) Other. If desired, the Patient may mark the “Other” checkbox then use the space provided to define exactly how or when this document’s release or authorization expires.

VI. Acknowledgement Of Rights

(19) Signature Of Patient. The signature of the Patient will be required to execute this instrument. Therefore once the Patient has completed documenting his or her desired authorization, he or she should review the content of this release, sign his or her name on the “Signature Of Patient” line, then print his or her name on line bearing the “Print Name” label. If a Representative of the Patient will be signing this document on his or her behalf, then this first signature area line may not be completed.

(20) Date. Upon signing, the Patient should record the current calendar date on the line labeled “Date.”

Patient Representative Signature (If Applicable)

Select And Complete Item 21 Or Item 22 Or Item 23

(21) Being A Minor. If the Signature Party is not the Patient, then the second signature area must be utilized by the Patient Representative. Before doing so, it will be necessary to discuss why the Patient is unable to sign this document. If the reason the Patient cannot sign this document is that he or she is a Minor and the Patient’s Guardian or Parent must sign on his or her behalf, then place a mark in the “Being A Minor” checkbox and document the age of the Patient on the blank space this explanation contains.

(22) Being Incapacitated. If the Patient cannot personally sign this document because he or she is physically or mentally unable to as a result of “Being incapacitated” then, select the second statement and describe the nature of the Patient’s incapacitation on the blank space provided.

(23) Other. If neither of the reasons above explains why the Patient requires a Representative to sign this instrument of consent on his or her behalf, then the “Other” checkbox should be selected and the exact reason why the Patient can not personally sign this document should be presented on the blank space in this option.

(24) Signature Of Representative. Once it has been established that the Patient is unable to execute this document by personal signature, his or her Representative should sign the “Signature Of Representative” line.

(25) Date. If a Signature Representative is executing this document on behalf of the Patient, then the “Date” line must be supplied with the calendar date of his or her signature.

(26) Relationship To Patient. The relationship held by the Signature Representative to the Patient must be presented. Therefore, select the checkbox labeled “Parent” if the Patient is the Signature Representative’s offspring. If the Signature Representative is the Patient’s “Spouse,” the second checkbox should be selected. If the Patient’s “Guardian” is signing this document on the Patient’s behalf then the third checkbox should be marked. If none of these relationships accurately define the Patient’s Representative, then select the “Other” checkbox and define the relationship the Patient’s Representative holds with the Patient on the blank space that follows.

Additional Consent For Certain Conditions

I. Sensitive Information

Select Item 27 Or Item 28

(27) Consent. An additional opportunity to provide consent has been provided to accommodate the authorization needed for the release of the Patient’s sensitive medical information (i.e. physical/mental/sexual abuse, drug abuse, STD’s, Abortion, etc.). If the Patient consents that such medical information should be included with the release completed above, then select the “I Consent” checkbox found in Article I of the “Additional Consent For Certain Conditions” page.

(28) Do Not Consent. If the Patient does not wish to authorize the release of sensitive medical information, then the “I Do Not Consent” checkbook should be selected. While sensitive medical information is considered confidential without the Patient’s deliberate consent in many cases, issuing this additional document will establish (for any Reviewers) the seriousness of the Patient’s objection to such a release and could be considered a wise precautionary measure.

(29) Signature Of Patient. In order for the status of this additional consent to be placed in effect, the Patent must sign then print his or her name on the “Signature Of Patient” line and “Print Name” line.

(30) Signature Date. The Patient should date his or her signature by entering the current date immediately after he or she has signed this paperwork.

II. HIV/AIDS

Select Item 31 Or Item 32

(31) Consent. If the Patient intends that his or her medical records containing HIV/AIDS information (i.e. history, testing status, current diagnosis) is authorized for release then the first checkbox from Article II should be marked.

(32) Do Not Consent. If the Patient does not consent to the release of any medical records containing information related HIV/AIDS, the second checkbox should be marked.

(33) Signature Of Patient. To set the Patient’s disclosure status on HIV/AIDS information in his or her medical records, the Patient must sign this document. This signature should be provided on the “Signature Of Patient” line. In addition, he or she should use the “Print Name” line to present his or her legal name in print.

(34) Date. The signature date of the Patient must be included in this disclosure status and should be supplied by the Signature Patient immediately after signing his or her name. The “Date” line provided should be used for this presentation.

Related Forms

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Download: Adobe PDF, MS Word, OpenDocument

Download: Adobe PDF, MS Word, OpenDocument

Download: Adobe PDF