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HIPAA Patient Information Release Request Form

Need to release your medical information? Fill out our HIPAA Patient Information Release Request Form to authorize the disclosure of your health records. Our secure and convenient online form ensures your privacy is protected. Easily submit your request and gain peace of mind knowing your information is being handled with the utmost care. Take control of your health information today.

3 minutes to complete

Eligibility

To complete the HIPAA Patient Information Release Request Form, you must be the patient or have legal authority to act on behalf of the patient.

Questions for HIPAA Patient Information Release Request Form

Questions

1.

Name of Patient

The answer should be a text input.
2.

What are you requesting?

The answer should be a single choice:
  1. Copy of my own records
  2. Send records to another provider/person
3.

If records are to be sent elsewhere, give recipient details.

The answer should be a text input.
4.

What information should be released? (check all that apply)

The answer should be a single choice:
  1. Entire medical record
  2. Medical history
  3. Lab results
  4. Imaging/radiology reports
  5. Billing/insurance records
5.

Do you want sensitive records included (e.g., mental health, substance use, HIV/AIDS status)?

The answer should be a single choice:
  1. Yes
  2. No
6.

Reason for requesting/releasing this information.

The answer should be a single choice:
  1. Personal use
  2. Continuity of care
  3. Insurance/benefits
  4. Legal purposes
7.

How would you like to receive the records?

The answer should be a single choice:
  1. Paper copy (mail/pickup)
  2. Electronic copy (secure email/portal/CD/USB)
  3. Fax (where permitted)
8.

Do you understand that you may revoke this request in writing at any time?

The answer should be a single choice:
  1. Yes
  2. No
9.

I request the release of my health information as specified in this form.

The answer should be a single choice:
  1. I agree
  2. I disagree
10.

Patient (or Personal Representative) Signature

The answer should be a signature.

Forms Similar to HIPAA Patient Information Release Request Form

  • Consent for Medical Records Release Form
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  • Health Records Disclosure Consent Form
  • Patient Health Information Release Request Form

Here are some FAQs and additional information
on HIPAA Patient Information Release Request Form

What is the HIPAA Patient Information Release Request Form?

The HIPAA Patient Information Release Request Form is used to authorize the release of a patient's protected health information.

Who can request access to a patient's information using the form?

Only the patient or their authorized representative can request access to a patient's information using the HIPAA Patient Information Release Request Form.

How is the privacy of the patient's information protected when using this form?

The HIPAA Patient Information Release Request Form ensures that the patient's protected health information is only shared with authorized individuals or entities.

Can healthcare providers share a patient's information without their consent?

Healthcare providers must obtain the patient's consent through the HIPAA Patient Information Release Request Form before sharing their protected health information.

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