The Medical Records Release Form (also known as a Medical Records Authorization Form) is essential for maintaining patient privacy while facilitating necessary information sharing in healthcare settings. This document is required whenever protected health information needs to be shared with parties other than the direct healthcare provider. The form must comply with HIPAA regulations and often more stringent state laws. A properly executed Medical Records Release Form includes patient identification, specific information to be released, duration of authorization, and clear documentation of informed consent. It's particularly important in cases involving insurance claims, continuing care, legal proceedings, or research purposes.
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1. Patient Information: Full name, date of birth, contact information, and patient identification number
2. Healthcare Provider Information: Details of the provider/facility releasing the records
3. Recipient Information: Details of person/entity authorized to receive the records
4. Information to be Released: Specific description of medical records to be released
5. Purpose of Release: Stated reason for the release of information
6. Duration of Authorization: Expiration date or event for the authorization
7. Patient Rights Statement: Required HIPAA statements about patient rights regarding the authorization
8. Signature Block: Space for patient/authorized representative signature and date
1. Sensitive Information Authorization: Specific authorization for mental health, HIV, substance abuse records - use when releasing sensitive health information requiring special authorization
2. Fee Information: Details about any costs associated with records release - use when the provider charges for records copies
3. Electronic Delivery Authorization: Specific authorization for electronic delivery methods - use when records will be delivered electronically
1. Fee Schedule: Detailed breakdown of copying and processing fees
2. State-Specific Notices: Required notices or statements specific to state law
3. Identity Verification Form: Additional form for verifying requester identity
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