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HIPAA Compliant Release Form Template

Here's what you'll find in the HIPAA Compliant Release Form:

  • A contract template to be used by either an individual or their respective representative to release medical records to an outside party.
  • Tips on things to avoid, key items to pay attention to, and general resources which may be helpful
  • Advice on getting contracts signed quickly, digitally, and legally
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HIPAA Release Form Template

A HIPAA release form is a formal medical records release. It is an important document used by either an individual or their respective representative to release medical records to an outside party.

Here’s what you will discover in the HIPAA Release Form Template:

  • An actual HIPAA release form ready to download and customize
  • A comprehensive guide outlining the importance of a HIPAA release form
  • An easy to follow form highlighting the essential elements of a basic HIPAA release form.

What is a HIPAA Release Form?

A HIPAA release form is a simple medical records request form. It is utilized by an individual or authorized representative to request the release of their medical records to a named party. The release can permit family members, friends, other health care providers, lawyers, or any other third-party access to their personal medical records.

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to protect an individual’s protected healthcare information. A HIPAA compliant release is required before a person’s protected health information, and medical records can be released. HIPAA is a federal law that provides that patients are entitled to a copy of their medical records in any medium requested (physical or digital). Depending on state-specific laws and regulations, medical providers may charge a reasonable fee for the cost or reproduction of medical records.

Other names for a HIPAA Release form include

  • Records Release Form
  • Medical Records Release
  • Medical Records Request
  • Medical Records Authorization

Why is a HIPAA Release Form Necessary?

HIPAA provides that you have an irrefutable right to your medical records. It is always helpful to have maintained copies of your medical records from your healthcare providers. HIPAA requires your consent before medical records can be released to any outside party. Any time medical records need to be released patient or other organization, a HIPAA form is required illustrating the patient’s consent.

When do I Need a HIPAA Release Form?

A HIPAA release form is required in order for a healthcare provider to release your protected health information. You are entitled to a copy of your medical records; however, there are times when you may need to allow access to another party. A common instance is in a personal injury matter. When a party seeks reimbursement of medical expenses, a lawyer may need copies of any relevant medical records. The medical records can also provide the attorney with specific details related to injuries sustained as a result of an automobile accident. Other parties that may need access to your medical records include:

  • A Legal Guardian or Representative
  • Insurance Companies
  • Employers
  • Other Healthcare Providers and Organizations (hospital records, primary doctor, chiropractor, dentist, Medicaid, Medicare, HMO, etc.)

What Information is Included in a General HIPAA Release Form?

The purpose of a HIPAA release form is to obtain the patient’s permission to release medical records to a third-party. A HIPAA release form should include the following:

  • The patient’s name, social security number, date of birth, phone number, and email address
  • The organization’s name, address, phone number, and fax number the information shall be released to.
  • The types of records authorized to be released (test results, treatments, x-rays, images, laboratory tests, progress notes, or other noted records listed in the HIPAA release form.
  • The length of time the HIPAA release is valid.

Common Mistakes in HIPAA Release Forms

It is suggested that the duration of the medical release is established. This avoids any unauthorized access to your medical records in the future. Most patients allow a HIPAA release form to be valid for one or two years from the patient’s signature.

Another common mistake found in HIPAA release forms is incorrect or inaccurate information. The information should be up-to-date and adequately list the organization’s information or other third-party you are granting access to. Ensuring the information is accurate saves you time, money, and any potential delay in obtaining your medical records. Additionally, it is wise to consult with an attorney to confirm you are in compliance with HIPAA and any state-specific laws and regulations.

How to Get Your HIPAA Release Form Signed

Look no further, you have found it here on ApproveMe. Your HIPAA release form can be created quickly and easily on this site. Our HIPAA release form template simplifies the drafting and signature process offering an all-inclusive platform to satisfy your signature needs. ApproveMe is user-friendly, secure, and helps you obtain legally binding electronic signatures.

Where can I Learn More About HIPAA?

Here are a couple of helpful sources to help you navigate the ins and outs of HIPAA:

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HIPAA COMPLIANT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS AND INFORMATION

1. The following specific person(s) or class of persons or facility is authorized to make the requested use or disclosure:
________________________________________________________________________________________________________________________________________________

2. I, _________________________, hereby authorize the use or disclosure of protected health information concerning myself to the following person(s) or class of persons: ________________________________________________________________________________________________________________________________________________

3. I also request that the Medical Records be released to the following:

Organization/Individual’s Name: _______________________________________
Address: __________________________________________________________
__________________________________________________________________
Phone Number: __________________
Fax Number: ___________________

4. The specific information that should be disclosed is all medical records, treatments, x-rays, diagnostic laboratory test results, progress notes, and any other similar medical records on me.

Other:__________________________________________________________________________________________________________________________________________

5. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

6. I may hereby revoke this authorization by notifying _________________________ in writing of my desire to revoke it. However, I do understand that any action already taken in reliance of this authorization cannot be reversed, and my revocation will not affect those actions. I understand that my refusal to sign will not affect my ability to obtain treatment from or the payment to the medical provider to whom this authorization is furnished.

7. The purpose of the requested use or disclosure is at the request of the individual patient.

8. I ask that the Medical Records be released within the next thirty (30) days as required by the Health Insurance Portability and Accountability Act (“HIPAA”)

9. This release will be valid until ______________________, or until written notice is sent by me therefore revoking the release before the aforementioned end date.

Patient Information
Full Name
Social Security Number
Date of Birth (mm/dd/yyyy)
Address

Phone Number(s)

Email Address

__________________________________
Signature of Patient/Claimant

______________________
Date

-or-

Authorized Representative of the above-referenced Patient:

Full Name: __________________________

__________________________________
Signature of Authorized Representative

______________________
Date

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