Medical Records Release Form (US)

Patient Information

Full Name:

Date of Birth:

Street:

Town/City:

State:

Country:

ZIP Code:

Home Phone Number:

Cell Phone Number:

Email:

Is the Patient a minor or dependent adult? A minor is someone who is under the age of majority in their residing state. For example, in the state of Montana the age of majority is 18. A dependent adult includes someone who is under another’s care by way of medical directive, power of attorney, court order, etc.

Yes

No

Frequently Asked Questions

Who is the Patient?"Patient" is the individual who is seeking to have Medical Records released.

Current Location of Medical Records

Organization Details

Name:

Please insert the doctor's office, clinic, hospital, etc. name here.

Street:

City/Town:

State:

ZIP Code:

Country:

Fax Number:

Phone Number:

Add another organization

Frequently Asked Questions

Who is the Organization?The Organization is the entity that holds the Medical Record for the Patient, and is where this Medical Records Release should be sent. The Organization could be a doctor's office, clinic, hospital, allied healthcare clinic (such as a chiropractor, physiotherapist, or massage therapist), HMO, Medicare, or Medicaid.

Sharing Medical Records

Will the Patient's Medical Records be shared?

Yes

No

Frequently Asked Questions

Who should have access to the medical records?The Patient’s Medical Records may be shared with other healthcare providers, and with individuals/organizations that the Patient and/or Legal Representative specify below. Common examples of non-healthcare providers that may require Medical Records include insurance companies, lawyers, employers and exercise facilities.

Medical Records Correction

Are Corrections to Medical Records required:

Yes

No

Frequently Asked Questions

What should I do if there are errors within the medical records?If there are identified errors within the Patient’s existing Medical Records, you may ask for them to be corrected using this Release.

Duration of Medical Release

This Medical Records Release is valid until:

To prevent the unauthorized disclosure of your Medical Records in the future it highly recommended that you limit the duration of your Medical Records Release to less than two years.

Signing Details

Date Release will be signed:

City/Town where signed:

State:

Ohio

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Patient Information

Guardian/Legal Representative

Current Location of Medical Records

Organization Details

Sharing Medical Records

Medical Records May Be Released to the Following:

Organization/Individual

Medical Records Correction

Duration of Medical Release

Signing Details