A Medical Release Letter is essential in healthcare settings where protected health information needs to be shared between different parties. This document, governed by HIPAA regulations and state-specific requirements in the United States, serves as legal authorization for the transfer of medical records. It's commonly used when patients need their records sent to new healthcare providers, insurance companies, or legal representatives. The letter must include specific elements required by law, such as clear patient identification, explicit description of information to be released, designated recipients, and temporal limitations of the authorization.
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1. Patient Information Block: Full legal name, date of birth, address, contact information, and medical record number of the patient
2. Authorization Statement: Clear and explicit statement of consent authorizing the release of medical information
3. Information Details: Specific description of what medical information is authorized for release, including date ranges and types of records
4. Recipient Details: Complete information about the person or organization authorized to receive the medical information
5. Duration and Expiration: Specific timeframe for which the authorization is valid, including expiration date or event
6. Rights Statement: Statement of patient's rights including right to revoke authorization and right to refuse to sign
7. Signatures Block: Space for patient or authorized representative signature, date, and any required witness signatures
1. Special Categories Authorization: Additional specific authorization for sensitive information such as mental health records, HIV status, or substance abuse treatment
2. Purpose of Release: Statement describing the specific purpose for releasing the medical information
3. Electronic Delivery Authorization: Specific authorization for electronic transmission of records, including email or portal access
4. Re-disclosure Notice: Statement regarding potential re-disclosure of information by recipient and limits of privacy protection after release
1. Identity Verification Documents: Attached copies of government-issued ID or other required verification documents
2. Legal Authority Documentation: Attached power of attorney, legal guardian documentation, or other proof of legal authority to request records
3. Specific Records List: Detailed itemized list of specific records being requested, if extensive or complex
4. State-Specific Forms: Any additional state-required forms or documentation for medical release
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