Sample medical records release form pdf

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There are two primary forms of medical release letters. For example, you might draft one if you want a doctor to release your medical records to another person. A different kind of medical release sample medical records release form pdf an adult the authority to seek medical treatment for your child. You might need to sign one of these releases before your child can go on a field trip or play sports.


You can set up your letter like a standard business letter. Make sure to use a font that is readable. For example, Times New Roman or Arial 12 point works best.

You can address the letter to the doctor or medical provider who maintains the records you want released. If you are a medical provider, then you might want to draft a form that your patients can use. Set it up as a template, and insert blank lines for information that will change depending on the patient. You need to explicitly identify which doctor you are giving permission to release your information.

You also should identify who they should release your medical records to. I authorize Piedmont Medical Practice to use and disclose my protected health information described below to Dr. Caryn Smith, 2222 High Street, City, Nevada, 12345. State the time period for disclosures.

You should identify what time period of treatment this release relates to. For example, you could have seen your doctor for the past 10 years, but you only want to release information from the past two years. This authorization for release of health information covers the period of healthcare from August 1, 2013 to April 2, 2016. Identify what information to release.

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