Medical Release Instructions
To watch a video on how to fill out this document, click below.
On the top of the Page the To line you should enter the name of the provider's name that you are requesting to release your information. This is the holder of the records. Enter the Office Name, Doctor's Name, Address, Phone Number and Fax Number, if available.
Section I: Enter your name, your full address, date of birth and phone number. Here you are identifying yourself as the patient/patient representative authorizing the release.
In the next part of this section, you need to identify what specific information you are authorizing the release for. It can be your entire medical file, or just lab or imaging records or you may limit the release to a certain treatment or procedure, or you may enter any other specific item.
You should initial on the line of what information you authorize to be release.
Section II: Release-In this Section you will enter the name of the third-party, be it person, entity or organization that will receive the authorized medical records.
Enter the name of the Person or the entity, the address, phone number, fax number and email.
If you want your information to be released to yourself, enter your own information.
Section III: Duration- In this section you can limit the amount of time that the release is valid for. It is a good idea to limit the amount in order to prevent your health information from being improperly disclosed.
Enter the date that you want your authorization to end. If you do not want to limit the duration of your authorization enter not applicable.
Section IV: Specific Conditions- certain conditions due to their sensitivity required a separate consent to be released. Those conditions include: physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatments. If you want any information relating to these conditions to be released initial the line next to the consent line. If you do NOT consent place your initials on the line that states "I do not consent."
Section V: HIV/AIDS- in this section you may either consent or not consent for the release of medical information relating to HIV and/AIDS. Place your initial next to the line that you select.
Signing Sections: Enter the date that this Authorization will be signed on. Enter the date of the month, then the Month and then the year. For example: 20th day of August, 2023. Sign on the line. It is best to sign this document in front of a witness. Have the witness sign by the Witnessed By line and print their name on the witness name line.
Minors/Unable to Sign:
Please select if patient is a minor and enter the age or if patient in unable to sign, enter the reason such as incapacity.
If the Patient is a minor or is unable to sign, then the Legal Representative must fill out this section. If a person in unable to sign, then the name of their Authorized Representative must entered and signed. The Legal Representative or Authorized Representative may be a parent, legal guardian, representative by court order, or other.