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Health Information Manager
25-30 minutes

HIPAA Compliance Guidelines for Releasing Medical Records

The s10.ai Medical Records Release Form (HIPAA-Compliant) is an indispensable resource for healthcare providers and medical record administrators, designed to ensure the secure and authorized exchange of patient health information in full compliance with HIPAA standards. This template features comprehensive sections for obtaining patient consent, detailing specific health information to be disclosed, specifying the purpose of disclosure, and identifying authorized recipients. Additionally, it clearly defines the duration of authorization and outlines revocation rights. By safeguarding patient privacy while enabling essential information sharing, this template is a critical asset for healthcare organizations and medical record administrators seeking to enhance their operational efficiency and compliance.

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Dr. Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Please fill out all parts of this HIPAA authorization form. If any sections are incomplete, this form will be invalid, and your health information cannot be shared as requested.
Section I
I, [insert full legal name of the individual authorizing release] (insert full name of the person giving permission exactly as stated in official records; only include if explicitly provided), authorize [insert name of the healthcare organization authorized to release the information] (insert full name of the organization responsible for disclosing the health information; only include if explicitly mentioned) to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.
Section II – Health Information
I authorize the above healthcare organization to: [insert statement describing which records should be disclosed] (only include one of the following options as applicable: full health record disclosure including diagnoses, lab test results, treatment, and billing; OR full health record excluding specific categories — mental health records, communicable diseases including HIV/AIDS, alcohol/drug abuse treatment records, genetic information, or other; must match user's explicit selections. Presented in line format.)
Form of Disclosure: [insert format of disclosure, such as 'Electronic copy or access via a web-based portal' or 'Hard copy'] (include only if specified. Match formatting exactly as in original — i.e., on the same line, not listed unless shown that way in the original.)
Section III – Reason for Disclosure
Please specify the reasons for sharing information. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’.
[insert reason for disclosure] (write a short paragraph in full sentences detailing all relevant reasons for requesting the release of information, as described by the individual. If the patient simply writes "at my request", include that exact phrase. Do not paraphrase or summarize.)
Section IV – Who Can Receive My Health Information
I authorize the health information detailed in section II of this document to be shared with the following individual(s) or organization(s)
Name: [insert full name of recipient individual] (enter only if explicitly provided)
Organization: [insert name of recipient organization] (enter only if explicitly provided)
Address: [insert full mailing address of recipient] (enter complete address exactly as stated; only include if mentioned)
I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.
Section V – Duration of Authorization
This authorization to share my health information is valid:
[insert selected timeframe option from the following]
a) "From" [insert start date] "to" [insert end date]
Or
b) "All past, present, and future periods"
Or
c) "The date of the signature in section VI until the following event:" [insert description of triggering event]
(Select only the option that was explicitly chosen by the individual completing the form. Keep formatting inline and identical to the original.)
I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
Name: [insert recipient name for revocation notice] (include only if mentioned)
Organization: [insert organization name for revocation notice] (include only if mentioned)
Address: [insert mailing address for revocation notice] (include only if mentioned)
I understand that:
- In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
- I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.
- I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI – Signature
Signature: [insert handwritten or digital signature of the individual] (include only if explicitly provided)
Date: [insert date of signature] (include only if explicitly provided)
Print your name: [insert full printed name of individual signing the form] (include only if explicitly provided)
If this form is being completed by a person with legal authority to act on an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:
Name of person completing this form: [insert full name of legal representative] (only include if applicable and explicitly stated)
Signature of person completing this form: [insert representative's signature] (include only if provided)
Describe below how this person has legal authority to sign this form:
[insert explanation of legal authority] (write a short paragraph or list format — matching the example — describing the legal basis for the person’s authority to complete and sign the form on behalf of the individual.)
Sample Clinical Note

Example of completed documentation using this template

Medical Records Release Form (HIPAA-Compliant)
Section I  
I, John Doe, authorize s10.ai to disclose the information specified in Section II of this document to the individual(s) or organization(s) I have identified in Section IV of this document.
Section II – Health Information  
I authorize the aforementioned healthcare organization to: provide full health record disclosure, including diagnoses, lab test results, treatment, and billing.
Form of Disclosure: Electronic copy or access via a web-based portal
Section III – Reason for Disclosure  
At my request.
Section IV – Who Can Receive My Health Information  
I authorize the health information detailed in section II of this document to be shared with the following individual(s) or organization(s)
Name: Jane Smith  
Organization: Health Insurance Co.  
Address: 123 Insurance Lane, Suite 100, Metropolis, NY 10001
I understand that the person(s)/organization(s) listed above may not be governed by state/federal rules on data privacy and security and may be allowed to further share the information provided to them.
Section V – Duration of Authorization  
This authorization to share my health information is valid:
From 1 November 2025 to 1 November 2026
I understand that I can revoke this authorization to share my health data at any time by submitting a written request to:
Name: Jane Smith  
Organization: Health Insurance Co.  
Address: 123 Insurance Lane, Suite 100, Metropolis, NY 10001
I understand that:  
- If my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.  
- I do not need to provide any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.  
- The failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI – Signature  
Signature: John Doe  
Date: 1 November 2024  
Print your name: John Doe
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive HIPAA release form template is designed to streamline the process of authorizing the disclosure of health information, ensuring compliance with privacy regulations. By meticulously completing each section, healthcare professionals can facilitate the secure sharing of patient data, whether for full health record disclosure or specific exclusions. The template includes clear instructions for specifying the format of disclosure, reasons for sharing, and authorized recipients, making it an essential tool for maintaining patient confidentiality while enabling necessary information exchange. Clinicians are encouraged to adopt this template to enhance their practice's efficiency and uphold the highest standards of patient privacy and data security.
Frequently Asked Questions

Common questions about this template and its usage

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