Medical Release Form Template with Examples - Heidi Health | Heidi AI
Medical Release Form Template with Examples
Shine Colcol
Organic Growth Lead•February 11, 2026•21 min read
Fact checked by Dr. Ben Condon
Medical Release Form
This medical release form template enables clinicians and administrative staff to quickly provide patients with a ready-made form to authorize the release of medical records. The template meets HIPAA guidelines and may also be suitable for practitioners governed by other privacy and confidentiality regulations.
Suitable for clinicians of all backgrounds
Includes specific check-boxes to cover sensitive information (e.g., mental health and communicable diseases)
Form structure can easily be adjusted using the AI assistant in Heidi’s template editor
A medical release form (also known as a medical records release form or authority to release medical information) is a legal document patients can sign to permit healthcare providers to share their private health information with specified third parties.
It’s widely accepted that a degree of information sharing is required to facilitate the safe and effective delivery of medical care. Therefore, providers only need to obtain a medical release form from patients under certain circumstances.
In the US, medical release forms are designed to comply with privacy laws such as the Health Insurance Portability and Accountability Act (HIPAA). While in Australia and the UK, medical confidentiality is primarily governed by common law (along with a duty of confidentiality being outlined in various regulations and codes of practice).
In this article, we’ll outline the situations in which a medical release form is required before covering the main challenges clinicians face with these important documents. We’ll then provide examples of medical release forms, including a range of free downloadable templates.
When to Use a Medical Release Form
Clinicians can legally share a patient’s information in many situations involving the routine delivery of care. For example, if a patient sees their primary care doctor and then needs input from the clinic nurse, the patient would reasonably expect relevant background information to be given to the nurse.
However, it’s vital that patients have certain assurances that their private information will not be inappropriately shared, as this creates the basis of trust upon which effective patient-clinician relationships are built.
Broadly speaking, a medical records release form is required for situations where there is no reasonable expectation on the patient’s behalf that their information would be shared.
To unpack when it might be necessary to use a medical release form, we must first cover some basic concepts around privacy and confidentiality in healthcare settings.
Medical Records Release Forms: Privacy and Confidentiality 101
While the terms are commonly used interchangeably, privacy and confidentiality relate to different aspects of information sharing in healthcare.
Privacy refers to laws and regulations around how patient information can be collected, handled, used, and accessed. These laws inform regulations that mandate things like the secure storage of patient information, restrictions around using collected information for marketing or research purposes, and patient’s rights over their data.
Confidentiality describes the healthcare provider’s obligation to protect patient information disclosed to them while delivering care. Confidentiality covers formal information sharing (such as a letter to social services) and informal sharing (like talking about a patient outside of work).
Australia does not have specific laws covering patient confidentiality. However, common law, government regulations, and professional codes of practice stipulate that healthcare providers must uphold a duty of confidentiality. In the US and UK, patient confidentiality is primarily governed by HIPAA/GDPR, with common law and professional codes of practice also playing a role.
Understanding HIPAA
With its clear definitions of protected health information and covered entities, HIPAA provides a good framework for understanding when a medical release form may or may not be required.
What is Protected Health Information?
According to the HIPAA Privacy Rule, protected health information (PHI) encompasses individually identifiable health information that relates to:
The individual's past, present, or future physical or mental health or condition
The provision of health care to the individual
The past, present, or future payment for the provision of health care to the individual
In addition to clinical details, PHI includes information that may be used to identify an individual, such as demographics and Social Security Number.
The goal of the Privacy Rule is to “assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high-quality healthcare and to protect the public's health and well being.”
Permitted Uses and Disclosures of PHI
Clinicians are permitted to use and disclose PHI to a “covered entity” (health plan, healthcare provider, or healthcare clearinghouse) without an individual’s authorization for the following purposes:
Treatment, payment, and healthcare operations
Public interest and benefit activities (such as when required by law or to prevent imminent harm)
Giving the individual access to their own PHI
Outside the guidelines above, clinicians must obtain a signed release of medical records form before sharing PHI.
Furthermore, in instances where PHI is shared, only the minimum amount of information required to fulfill the request should be provided.
Medical Records Release Form Scenarios
Below are some examples of when a medical release form may or may not be required before sharing patient information.
Please note that these examples are a guide only. When in doubt, it’s always best practice to obtain a signed medical record release form before disclosing patient information.
A Medical Release Form is Generally NOT Required for:
Treatment purposes - Clinicians directly involved in a patient’s care (such as in an MDT) may share information without requiring separate medical release forms.
Payment operations - Sharing information with insurance companies for billing purposes usually doesn't require a medical release of information form.
Healthcare operations - Patient information may be used for quality assessment, audits, medical reviews, or other administrative functions.
Emergencies - Medical information can be shared to facilitate immediate treatment when obtaining consent would delay life-saving care.
A Medical Release Form IS Usually Needed Before:
Sharing records with third parties not involved in treatment, payment, or healthcare operations (such as employers, life insurance companies, or attorneys).
Releasing information to family members who are not legal representatives or healthcare proxies for the patient (such as the mother of a competent adult).
Disclosing specially protected information like HIV status, substance abuse treatment records, genetic information, or therapy notes.
Using patient information for commercial purposes or other reasons beyond treatment, payment, or healthcare operations.
Challenges with Medical Release Forms
In most cases, using a medical record release form is reasonably straightforward. A need to disclose information arises, the patient signs the medical release forms, and the clinician passes on the requested information. However, several challenges may arise due to the nature or circumstances of the disclosure.
Breaching Confidentiality Due to Risk
Clinicians sometimes face scenarios where maintaining confidentiality conflicts with a duty to protect the patient or others from harm. These situations may justify (or require) releasing confidential health information (like a mental state examination) without authorization from the patient.
When the patient poses a serious and imminent risk to themselves or others
When required by law or court order
Disclosing information to protect adults who lack decision-making capacity
When there is a public interest in disclosure (such as the prevention, detection, or prosecution of a serious crime)
US clinicians are similarly bound by the duty to protect principle, which stipulates (via legal precedents) that mental health professionals have a duty to protect potential victims from violent acts by their patients.
When confidentiality is breached due to risk, clinicians must keep impeccable records justifying their actions.
Release of Information Outside of Healthcare Systems
It’s common for clinicians to get requests for information from entities outside the healthcare system. Such requests may come from:
Social services agencies
Educational institutions
Family members and caregivers
Employers
Legal representatives
Insurance companies (for non-payment purposes)
As a general rule, clinicians can not release patient information without signed authority to individuals or organizations from the list above. Unless you’re satisfied a serious imminent risk exists, always ask the patient to complete and sign a medical release form before sharing information outside the healthcare system.
Deciding What Information to Send
Once a clinician is satisfied there’s a legitimate need to disclose patient information, the next step is deciding what information to share.
The Eight Caldicott Principles serve as a useful guide regarding information disclosure for clinicians of all backgrounds:
Justify the purpose for using confidential information
Use confidential information only when it is necessary
Use the minimum necessary confidential information
Access should be on a strict need-to-know basis
Everyone accessing confidential information must understand their responsibilities
Comply with the law
The duty to share information can be as important as the duty to protect patient confidentiality
Inform patients and service users about how their confidential information is used
In short, only the minimum necessary information should be provided to fulfill the purpose of the request.
For example, when writing a doctor’s note excusing a patient from work, the clinician should only indicate that the patient is unfit for work and for how long (not full details of their illness). If the employer wishes to make a formal request for more information (such as medical reports or discharge summaries) they can, but the patient would need to sign a medical release form to authorize this.
Time and Cost of Releasing Information
Processing medical release forms and preparing clinical notes for disclosure can be remarkably time-consuming. The process typically involves:
Verifying the authenticity of the request
Obtaining authorization from the patient
Locating the relevant records
Reviewing medical charts to ensure only authorized information is included
Documenting the disclosure in the patient's file
Securely transmitting information to the authorized recipient
Understandably, healthcare providers often charge for the provision of information or the transfer of records. However, this is not always feasible, resulting in increased administrative burden for clinicians.
Of all specialties, mental health professionals probably field the highest volume of requests for patient information. Indiana Health Group (IHG) is a large multi-specialty behavioral health practice using Heidi’s AI medical scribe to reduce the time clinicians spend on information exchange and clinical documentation.
Dr. Chris Bojrab, President of IHG, reports that in the first five months since implementing Heidi, his team saved 120,000 minutes in documentation time. While much of this relates to documenting clinical sessions, staff at IHG also use the AI scribe to automate letter generation (for attorneys, time off work, and referral letters).
Using Heidi’s Context feature is key to the reduction in administrative burden experienced at IHG. By uploading patient history into Context, clinicians can use AI to generate a shareable summary of specific aspects of care or treatment in seconds. Combined with Heidi’s ready-to-use HIPAA medical release forms, IHG clinicians are spending only a fraction of the time previously lost to handling requests for patient information.
Essential Parts of a Release of Medical Records Form
A release of medical records form authorizes the disclosure of patient health information while maintaining legal and ethical safeguards. The following components are essential to ensure accuracy, privacy, and compliance:
Patient Information - Full name, date of birth, address, contact details, and, if applicable, a medical record number. This ensures the correct identification of the patient and the records to be released.
Purpose of Request - A clear statement outlining why the records are being requested (for example, treatment coordination, insurance claims, legal proceedings, or personal access). Defining purpose limits unnecessary disclosure and supports privacy compliance.
Restrictions or Limitations - Any stated exclusions or conditions regarding which parts of the record may be shared (for instance, excluding mental health notes or sensitive results).
Dates of Service - Specific dates or date ranges for the requested records, ensuring that only relevant portions of the medical file are included in the release.
Recipient Information - The name, organization, contact details, and relationship to the patient of the authorized recipient. This defines exactly who may receive and handle the released information.
Revocation Clause - A statement informing the patient of their right to revoke consent at any time. This maintains patient control over their personal health information.
Authorization Signature and Date - A signed and dated authorization from the patient or their legal representative. This signature confirms voluntary consent and validates the form legally.
How to Complete a Medical Release Form
A medical records release form template is a straightforward document that requires little to no input from the clinician to complete.
In most cases, the process simply involves giving the patient a copy of a properly formatted form, answering any questions they might have, and then asking the patient to complete and sign the document.
When complete, a copy of the medical info release form should be given to the patient, with the original stored in the medical record. The expiry date should be recorded to prevent unintentional information sharing after the authority expires.
Below is an example of the main headings and structure of a medical release form.
Medical Release Form Template Example
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In most cases, clinicians can rely on a single form to cover all requests for information. However, there are times when a custom form is required. In these situations, you can draft a letter for the patient to sign or manually adjust an existing form, but both of these options take time and risk not complying with healthcare privacy rules and regulations.
Easier Medical Release Forms with Heidi
Heidi’s Template Community includes a comprehensive library of medical release forms suitable for clinicians in all locations and practice areas. You can adjust and edit forms on the fly with AI-powered transcription and smart dictation features, meaning you’ll never be caught without a suitable medical release form.
Here’s how to use a medical release form with Heidi:
Choose a template. If none of the examples in this article work for you, just search the Community to find one uploaded by a fellow clinician.
Fill and adapt the details. You can edit and add information to the form by typing, dictation, or even having the patient speak during the session.
Print or email the form to the patient. Once the patient has signed and returned the document you can release the specified information.
Trusted with over 1 million patient consults per week, Heidi is the AI scribe of choice for clinicians who want to save time on producing high-quality, compliant clinical documentation. Heidi meets or exceeds regional healthcare privacy and security standards (e.g., HIPAA, GDPR, PIPEDA, APP), ensuring patient data is always protected.
This medical records release form is designed specifically for clinicians practicing in California. It meets HIPAA guidelines and follows a straightforward yet comprehensive format that’s easy for patients to follow. The form be used to release case notes, EMR charts, treatment plans, and any other specified information.
Built to cater to the needs of behavioral health and infectious diseases clinicians, this sample medical release form focuses on more sensitive patient records. It has tick boxes and free text fields for patients to provide instructions about releasing mental health, drug and alcohol, and HIV/AIDS information.
This hospital release form is designed for patients to authorize the sharing of all or specified records from a single hospital admission (like admission notes, operative notes, or progress notes). In addition to standard demographic information, the form lists the facility and treatment date, the purpose of disclosure, and has simple check boxes for patients to stipulate exactly what they would like to release.
In most cases, the term medical authority letter refers to a document that grants an individual or organization the authority to make healthcare decisions on someone’s behalf (including accessing medical information, where appropriate). Such authority may be given when the person in question lacks decision-making capacity. It’s also used as a backup only to be enacted in cases of emergency.
What is the difference between a medical liability release form and a medical release authorization form?
Sometimes called a “waiver,” a medical liability release form limits a healthcare provider’s liability for adverse outcomes from a specified treatment or procedure. On the other hand, a medical release authorization form generally carries the same meaning as a medical release form, which is a document used by a patient to authorize a provider to release their private health information.
Can I create my own medical release form template?
You can create your own release of medical information form to give to patients. However, we generally recommend editing an existing template that’s had a medicolegal review, rather than creating a new template from scratch. This ensures you don’t inadvertently omit details required for protection against a claim of breaching confidentiality.
