Authorization To Release Medical Information Form

Authorization To Release Medical Information Form Template for United States

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Key Requirements PROMPT example:

"I need an Authorization To Release Medical Information Form for transferring my complete medical history from Mayo Clinic to my new specialist at Cleveland Clinic, ensuring specific inclusion of my cardiology records from January 2025 onwards."

Document background

The Authorization To Release Medical Information Form is a critical document in the U.S. healthcare system that enables the legal and compliant sharing of protected health information. Required by HIPAA and various state regulations, this form serves as documented proof of a patient's consent to share their medical records. It specifies what information can be shared, with whom, for what purpose, and for how long. The form is essential for maintaining patient privacy while facilitating necessary information exchange between healthcare providers, insurance companies, legal representatives, and other authorized parties. It includes specific provisions for sensitive information and must comply with both federal and state-specific requirements for medical information disclosure.

Suggested Sections

1. Patient Information: Full name, date of birth, address, and contact information of the patient

2. Healthcare Provider Information: Details of the healthcare provider/facility releasing the information

3. Recipient Information: Details of the person/entity authorized to receive the medical information

4. Information to be Released: Specific description of medical information authorized for release

5. Purpose of Disclosure: Stated reason for releasing the medical information

6. Duration of Authorization: Expiration date or event for the authorization

7. Rights and Disclaimers: Patient rights, including right to revoke and notice of redisclosure

8. Signatures: Patient or legal representative signature, date, and relationship if applicable

Optional Sections

1. Specific Authorization for Sensitive Information: Additional authorization for mental health, substance abuse, or HIV/AIDS records

2. Electronic Disclosure Authorization: Specific permission for electronic transmission of records

3. Payment Authorization: Authorization for any fees associated with records release

Suggested Schedules

1. Fee Schedule: Schedule of applicable fees for medical records release

2. State-Specific Addendum: Additional requirements specific to state law

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Business Associate

Clauses

Relevant Industries

Healthcare
Insurance
Legal Services
Research Institutions

Relevant Teams

Medical Records
Compliance
Legal
Privacy Office
Administrative Services

Relevant Roles

Medical Records Administrator
Healthcare Privacy Officer
Medical Office Manager
Compliance Officer
Healthcare Attorney

Industries

HIPAA: Health Insurance Portability and Accountability Act of 1996 - Includes Privacy Rule requirements, Security Rule requirements, minimum necessary standard, and patient rights regarding their health information

State Privacy Laws: State-specific medical privacy laws that may include additional privacy protections, specific requirements for mental health/HIV/AIDS/substance abuse records, and varying retention periods

42 CFR Part 2: Federal regulations specifically governing the confidentiality of substance use disorder patient records

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Covers electronic health record requirements and security breach notification requirements

ADA: Americans with Disabilities Act - Includes confidentiality requirements for medical information and accessibility considerations

Patient Identification Requirement: Mandatory element of the authorization form that must clearly identify the patient whose information is to be released

Information Description Requirement: Mandatory element specifying what specific health information is authorized to be released

Purpose Disclosure Requirement: Mandatory element stating the purpose for which the information can be disclosed

Recipient Identification Requirement: Mandatory element identifying who is authorized to receive the disclosed information

Expiration Requirement: Mandatory element specifying when the authorization expires (date or event)

Revocation Right: Mandatory statement explaining the right to revoke the authorization

Redisclosure Statement: Mandatory statement explaining that disclosed information may be subject to redisclosure by the recipient

Conditional Treatment Statement: Mandatory statement about whether treatment is conditional on signing the authorization

Signature Requirements: Mandatory elements including signature of patient or representative and date

Sensitive Information Authorization: Special authorization requirements for sensitive information such as mental health, HIV/AIDS, and substance abuse records

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Authors

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