HIPAA Medical Records Release Authorization Template

What Is a HIPAA Medical Records Release Authorization?

A HIPAA medical records release authorization is the legal document that allows healthcare providers to disclose your protected health information to people or organizations you designate. HIPAA (the Health Insurance Portability and Accountability Act) strictly prohibits healthcare providers from sharing your information without your written permission, except in limited circumstances.

This authorization form meets federal HIPAA requirements while including special provisions for sensitive records like mental health treatment, substance abuse records, and HIV-related information. You control exactly what information is released, to whom, and for how long.

 

Is This HIPAA Authorization Form Right for You?

You need this form if you're:

• Transferring care to a new doctor
• Providing records for a legal case
• Applying for life or disability insurance
• Requesting records for a second opinion
• Filing a workers' compensation claim
• Managing healthcare for a family member

You definitely need this form if:

• Your new specialist can't get records from your previous provider
• Your attorney needs medical documentation for litigation
• Insurance underwriting requires access to your medical history
• You need records involving mental health or substance abuse treatment
• You're acting as healthcare proxy for an incapacitated relative

 

 

Why Thousands Trust Legal GPS Templates

Save Money. Skip attorney fees for a standard HIPAA authorization form.

Save Time. Download instantly and complete in minutes.

Look Professional. Comprehensive format that healthcare facilities recognize and accept.

Stay Protected. Section 4D's sensitive category provisions with initials requirements ensure you consciously authorize any release of psychotherapy notes, substance abuse records, or HIV information.

 

 

Get Protected in 3 Simple Steps

Step 1: Secure Checkout. Complete your purchase through our encrypted payment system. You'll receive immediate access to your template.

Step 2: Instant Download. Download your HIPAA Medical Records Release Authorization in an editable format ready for completion.

Step 3: Fill In the Highlighted Fields. Follow the included how-to guide to identify the releasing provider, receiving party, and specific records to disclose.

 

Frequently Asked Questions

Can I use this template multiple times?

Yes. Once purchased, you can use this template as many times as needed. You may need separate authorizations for different healthcare providers since each facility maintains its own records.

Is this contract legally binding?

Yes, when properly completed and signed. This form is designed to meet federal HIPAA requirements under 45 C.F.R. § 164.508. Some states have additional requirements for certain record types, particularly mental health and HIV records.

What's the difference between "complete medical record" and "limited release"?

Complete medical record authorizes release of everything the provider has on file for you. Limited release lets you select specific categories, like only lab results or only records from a certain date range. Limited release protects your privacy when full disclosure isn't necessary.

Can I release my family member's medical records?

Only if you have legal authority as a personal representative. For minor children, parents or legal guardians can authorize release (with some exceptions for sensitive adolescent healthcare). For incapacitated adults, you need court-appointed guardianship or healthcare power of attorney. Section 10 covers documentation requirements.

What if I change my mind after signing?

You can revoke authorization at any time by providing written notice. Section 13 includes a revocation form. Revocation doesn't apply to records already released before the provider received your revocation notice.

Will this form work at any hospital or doctor's office?

This form meets federal HIPAA requirements, so healthcare providers should accept it. Some facilities have their own preferred forms but are legally required to accept a HIPAA-compliant authorization like this one. If a facility insists on their form, you can often complete both.