Medical Records Release Form

Patients use this authorization to direct a healthcare provider to release copies of their medical records to themselves, another provider, or a third party.

What’s Included

Patient identification, releasing and receiving parties, the records and date range covered, purpose, expiration and revocation notice, and the patient’s signature.

Important

This is a general-purpose template written in plain English, not an official government form. Requirements vary by state and country — review it, adapt it to your situation, and have a qualified professional check it before relying on it for anything significant.