Free Medical Release Form Template

You can download our Free Medical Release Form Template now.

A medical release form can be used for many different situations for either releasing medical records or releasing a part from liability.

Regardless of the type of medical clinic or hospital, before they will release any of your medical information and records you will need to complete and sign a medical release form.

It’s common for some clinics to charge for each copy of your medical records even if you are transferring them to another physician.

Unless required by a court order, the medical facility cannot release medical information without a medical release form completed and signed by the patient.

Also, unless you have power of attorney you cannot have fill out a medical release form for another individual, even if it is a family member.

Although many clinics keep free medical release forms available at their office it is not uncommon to find they are out of stock. So you may want to make sure you have one filled out before you request your medical records.

It can take up to a week before your clinic or hospital will release your medical information records.

Download your free medical release form template



Below is an example of a basic medical release form template.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

 

 

TO: _____________________________________________

_________________________________________________

_________________________________________________
 

 

You are authorized to release any and all medical records related to my medical condition and treatment that I may have had during the following time period listed immediately below:
 

From____________________ to ____________________

 

 

To the following person(s), company, or government institution: 

 

Name: ______________________________________________________________  

 

Address _____________________________________________________________

 

City, State, & Zip Code: _________________________________________________

 

 

______   My initials here indicate authorization to release all medical records requested.

 

 

A photocopy of this authorization shall have the same force and effect as an original. All prior authorizations are canceled.  
 

I have executed this document on the _____ day of______________ 201 (    )  

 

This Authorization Is Valid For 60 Days From The Date Of Execution. 

 

Name of Patient: _____________________________________________________  

 

Signature of Patient: __________________________________________________ 

 

Address of Patient: ____________________________________________________

 

City, State, & Zip Code: _________________________________________________

 

Phone Number: _________________________________

 

Date of birth: _________  Social Security Number: _________________