Free Medical Records (HIPAA) Standard Release Form Template

Medical Records (HIPAA) Standard Release Form

The medical records (HIPAA) standard release form, or the Health Insurance Portability and Accountability Act, is a legal document that is designed to protect a  patient, who is in the care of any health care provider or health care facility, from any person or persons who would willingly provide private information with regard to any aspect of their health care to others, without written permission to do so.

The HIPPA form allows the patient to authorize permission to a health care provider to acquire the records for their patient so they may make more informed decisions with a new patient’s medical services. The HIPPA form offers security to the patient from unauthorized access by family or health care providers who may not have the patient’s best interest at heart.

It’s very important to understand that once a health care provider has released the stated records to their recipient, that these sections of the records may not any longer be protected by federal law

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – Authorization –

  • Enter the name of the health care provider
  • Enter the name of the person requesting the health care information of the patient
  • If the patient would like to specify “to and from dates” check the box and enter the dates in line “a.”
  • If the patient would like to provide permission for the person to acquire all past records, they may do so by simply checking line “b.”

Step 3 – Extent of Authorization –

  • The patient must review a. and b. in this section and check the applicable box
  • If the selection would be line “b.” they will also need to specify any records that they wish not to have released
  • The patient must review paragraphs 4 through 8 (in paragraph 5, enter the date that the request for records by the stated individual shall expire, making the documents no longer available to outside sources

Step 4 – Signatures – Enter the following:

  • Signature of patient OR their personal representative
  • Printed name of the patient OR their personal representative
  • (If the personal representative is signing on behalf of the patient, state the relationship to the patient)
  • Date the document in mm/dd/yyyy format