Free Download Sample Medical Records Release Form and How To Request It

What Is Sample Medical Record Release Form?

It is allowed if a patient inspects or asking a copy of the medical records. Even they are allowed to have the copies of their medical records delivered to another facility. This document is provided by the hospital which consists of a complete date and sign. Keep in mind that each hospital has a different process. Sometimes it takes a few days to obtain this document. So, if it is the first time for you to request it, our sample medical records release form can be your reference that talks about what will the document bring to you.

Medical Records Request Form doc


How To Request A Medical Record?

Requesting a medical record is a complicated thing, so you should understand the rules, requirements and also the basic laws to shorten your process. The basic thing you need to understand that this is similar in most states. The person who is able to request the document is the patient itself and also the legal representative.

Medical Records Request Form

Even though there are some differences in some states, of course, these variations cannot against the states’ laws. In Ohio, the HIPAA applies to each person has the right to access his/her medical report and also receive the copies. Some hospitals add complexities because this document is sensitive information and should remain private while keeping the patients’ access to reach the document easier.

The first thing to do when asking the medical records is by contacting the health provider’s health information which is also known as the HIM department.

However, today many health providers also offer online access for certain services such as transferring files to another health provider. Therefore, if you have them sent your medical document, you need to provide the contact information and name. For example, if you are requesting your document to be sent to a new physician, you will need the physician’s full name, address and also fax number as well as the email address.

Furthermore, you are also able to request specific information and get the copies for your own or another health provider. However, specifying what records you need can be a difficult task. But you still can ask the professionals to narrow down your request. Because the medical record can be hundreds long.

Besides, for sensitive records such as behavioral health, HIV/STD records and also substance abuse needs additional authorization form. You can also request the format too. If the health provider that facilities using an electronic health record system, the format will be available in USB, CD or DVD. Even the patients can request the document to be sent by email.

If you are asking your document on your own, you will be required to provide a photo ID. Then, if you are picking another person’s record, you will need additional legal documents that demonstrate your right to access the document.

In terms of time, asking the medical record will take a long time despite its complicated procedures. Some hospitals will need to complete the documented maximum in 30 days. However, they will explain the reason why it should be delayed to the requestors. The main reason why such a document needs a long time is because of individual review requirements. Lastly, for the fee, some facilities have the right to ask fee in copying the records.


Sample Medical Records Release Form Authorization for Release of Medical Records Example Medical Records Release Form General Medical Records Release Form Medical Records Release Form Medical Records Release Form

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Get This Free Download Sample Medical Records Release Form

What Is Medical Records Release Form?

A medical release form is a document of the patient’s history which is saved by the hospital. This document is usually asked by the legal representative or patients’ to be sent to other facilities or to inspect the copy. The document has date and sign and each hospital has different regulation. Therefore, sometimes asking a medical records release form will take a few days. But sometimes we just want to know about the content in the document and what kind of thing that will be explained inside. Therefore, the sample medical records release form in this page is uploaded for free for you. You can learn it from our samples and even this is also editable.

Example Medical Records Release Form 1


What Is HIPAA and What Is It For?

The HIPAA stands for the Health Insurance Portability and Accountability Act. This document will allow someone to list the names of the family, relatives, health care providers, friends, clergy and other third parties to get access to the information. Therefore, if someone is asking a medical record of someone and their names are not listed in the HIPAA, they cannot obtain it because this information is considered to be private.

General Medical Records Release Form 1


Will We Have To Some Fee When Requesting A Medical Record?

For some cases, requesting a medical record will not be charged by the hospital, but the hospital will notify everyone in advanced when a fee is applied. Furthermore, asking a medical record for the representative will not be allowed if they don’t have the written authorization from the patients except it is permitted by the law.

Medical Records Release Form 1 1


How To Request A Medical Record?

Accessing a medical record is under your local law, so make sure you follow it. Besides, it can take several days to be completed. Usually, it takes within 30 days. Here are some steps on how to request the medical records.

Medical Records Release Form 1


Requesting Medical Form Through A Form

There are four sections you should write which are releasor and recipients, record types, time period and also the expiration date. You can use the standard form on our page. It is available for free. But if your hospital wants you to use their format, use it and write it neatly.

Medical Records Request Form doc 1


Sending The Letter

It is better to notify the hospital what kind of document you need. It can be in written, audio, or video documents. You can request it in the form of CD, Flash Drive and also PDF/Word.

Medical Records Request Form 1


Receiving The Medical Records

Receiving a medical record can be quiet long. If you don’t get the medical record within 7 business days, then the requestor or your legal representative should call the hospital to know the status of its transfer. The maximum day you should wait for receiving the medical record can be 30 days. But if they cannot meet this date, they will send a letter to the requestor telling why the request is delayed. Usually, it only takes one extension period allowed.

Sample Medical Records Release Form 1

If you are requesting a medical record by someone else, you need to follow certain regulation based on your local law and it is asked by your representative, the guardians and another third party that is allowed. So, make sure you are listed here and guaranteed by the law.



Authorization for Release of Medical Records 1

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