How to Create a Medical Release Form

Handling healthcare information is a big responsibility. Legislation like the Health Insurance Portability and Accountability Act and the Patient Protection and Affordable Care Act are serious about patient privacy. They place steep sanctions on healthcare personnel who mishandle patient information.

A medical release form is a document that gives healthcare professionals permission to share patient medical information with other parties. Under HIPAA regulations, it’s referred to as an “authorization.”

According to the U.S. Department of Health and Human Services, “An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.”

A release doesn’t give the healthcare staff permission to share information with just anyone. Depending on the scope of the document, the form may release medical information with the patient’s family, insurance providers, other doctors, attorneys, or anyone who may make healthcare decisions on behalf of the patient (a school, a parent or guardian, etc.).

Verbal medical release agreements are not sufficient because they are impossible to verify if there’s ever a disagreement. Healthcare staff need a written copy on record with a signature to protect themselves. If you are ever instructed to share healthcare information on behalf of a patient, make sure you have them sign a release form.

Patient’s Ability to Sign

A medical release form can only be completed by a patient who is sound in mind and body. If you have a reason to think to patient isn’t mentally capable of making the decision to release medical information, or if they have a physical condition (like intense pain) that might influence their decision-making abilities, you can’t accept the release form.

In fact, you can be held accountable for improperly sharing medical information if it can be proven that you were aware the patient wasn’t capable of making the decision to release the information. If you aren’t sure about the patient’s soundness to make medical decisions, have the patient’s spouse (or anyone who can make decisions in their stead) also sign the form.

Elements of a Release Form


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These are the main elements of a patient release form. The information may vary depending on your practice, industry and patients. Request any additional information you need. The goal is to protect yourself from potential liability.

(If you use online forms for your releases, check out tips to optimize your forms.)

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1. Patient Information

Naturally, the release should require the patient’s information so it’s clear who the form refers to. Create forms that require the patient’s name, phone number, address, email address, date of birth, social security number, and any other identifying information you think would be valuable.

Sometimes a parent will need to release medical information on behalf of their child. Often this information is sent to schools, athletic leagues, insurance companies or other doctors. They need this information to be aware of contagious diseases and verify immunizations. School nurses or EMTs may need it to treat illness or injuries on site. Make sure your forms have proper lineage for the child’s information.

2. Receiving Party’s Information

Insist that the patient clearly state who may access the medical information. This should include names, titles, addresses, and contact information so you are precisely clear.

Some patients aren’t private with their medical information and may want to give you permission to share their records with anyone. Never do that. Insist they give you explicit permission for each party so there’s no confusion.

We recommend that you have your patients complete a new form for each receiving party. Separate forms allow you to pair different types of information with different receivers.

For instance, a patient may want information shared from his general practitioner to his ear specialist, but only information that relates to his ears. He wouldn’t want to share last year’s X-rays of his broken foot. A specific medical release form for the ear specialist would limit the type of information shared for that receiver.

Be absolutely clear who should receive the information by creating fields for business name, name of the healthcare provider, address, email, phone number, place of business, and other identifying information.

3. Information to be Shared

Have the patient explicitly list the types of information, tests, results, scans, images, or notes to be shared. The patient can limit information any way they please, such as by body part, by condition (cancer, physiological disorder, pregnancy, etc.), date, and so on. Ask them to be thorough.

4. Purpose of the Release

The patient should indicate why their healthcare information is being released. These fields on the form are important to eliminate confusion and prevent the unintended spreading of information. Typical options include:

  • Social Security certification
  • Medical disability claim
  • Insurance claim
  • Worker’s compensation claim
  • Inform child’s school nurse
  • College immunization notification
  • Specialist consultation

5. Authorization Expiration

This field gives the patient an opportunity to record a date when the release form expires. It’s smart to add a note that if a date isn’t provided (common when the patient doesn’t know the outcome of treatment or how long it will take), the form will expire in 90 days. (You can use any length of time you like, but 90 days is standard.)

Yes, this means you might have to request additional release forms when they expire, but it’s smart to protect your business by getting as much written approval as possible.

6. Disclaimers

Disclaimers give patients information about how the form will be used and their rights. Make the patient aware that they are under no obligation to release their information and can revoke their release form at any time. List any fees associated with copying and distributing information.

7. Date and Signature

Finally, end your release form with a signature field and date. If you use an online form, patients can sign them with an e-signature.

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Distributing Medical Release Forms

HIPAA is a good law that protect patients’ privacy, but it comes with some challenges. It’s difficult to safely transfer healthcare information, even when the transfer is well-intentioned.

For example, a sick woman is being cared for by her niece. The niece wants to consult her aunt’s doctor about a potential medication reaction, but the doctor can’t discuss the aunt’s treatment because he doesn’t have authorization. In this case, the aunt needs to sign a medical release form, but she’s too sick to travel to the doctor’s office.

This is why it’s important to make your medical release forms accessible to your patients. Paper release forms are a big headache for everyone. Like any other medical record, release forms are best managed electronically. The benefits of electronic medical records are significant (they even save money).

online-medical-release-formYou can use online forms for your medical releases in two ways.

  1. Link to it on your website. You can direct anyone to the link when they request a form. Upon submitting the form, the information will appear in your recordkeeping system.
  2. Email a link to the form to your patient. This is the more effective method because it reduces the number of steps for your patient to take.

Using our earlier example, the doctor could email the form to the aunt and receive authorization in minutes. The aunt gets proper care and the doctor is protected. Everyone wins. (Just make sure your emails are HIPPA compliant.)

With IntakeQ you can quickly make medical release forms for your patients. Try it free for 14 days.

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