Medical Release Form Template

Medical Release Form Complete Templates for Documents, PDF, and Words

Medical Release Form is seen as a document that gives the authority and permission for professional healthcare to share medical information of patients to other parties. By having this document, the record information can be shared to certain people.

It can be shared to patients themselves, to the third party like family relations, insurance company, employees, company, and more. A healthcare provider such as physician, psychiatrist, dentist, hospital doctors, or other specific members such as chiropractor can send request form.

A request form about patients’ medical record to be released in a formal way and under the protection of formal law is what the sample medical release form will present. A patient can also request for the personal record of the medical information by following the right form.

How to Make Excellent Medical Release Form

To request a medical record, you need to be able to create a great letter. You need to put certain important information in the letter. It starts with your full name, date of birth, a social security number, the information of complete address and phone number.

It will be helpful to put email address in the form along with the list of the records that you are requesting. While you are doing this, you need to put the information of the service date and the delivery option. It means how the document can be sent to through fax, mail, or in person.

What Elements Included in the Medical Release Form

In the medical letter, there are several elements that you need to put in the form. The elements will point out the subject why the document needs to be released. The person can sign the subject that is related with the real condition.

Those elements are written down after the first paragraph of introduction and the full patient’s name and date of birth section. The subjects that you can sign are the complete records, treatment record, medication record, several reports and other subjects.

Some of the reports that can be added here is pathology reports, hospital reports, radiology reports, operative reports, lab reports, history & physical record data, progress notes, and other things. A good form needs to point out and emphasize about the releasing statement.

This statement is written under the subjects form. You need to state you are giving permission for the healthcare member to use and release your medical information that has been protected. This form also gives the protection of the medical information itself.

You need to give complete information of the healthcare that you are pointing out. It includes the name of the physician, healthcare person, medical facility or entity that takes care of the form, with the complete address that evolved name of the city, state, and zip code.

As an addition, it is important to write the purpose or the reason why the personal medical information is released in the following paragraph. Lastly, you need to put signature to authorize and legalize the medical release form to be used in the future for medical purpose.



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