Medical release forms must follow HIPAA regulations and include patient demographics, the name of the person or entity receiving the information, specific health information being disclosed and the reason for the release. Also, release forms must be signed, dated and include certain privacy disclaimers, states the National Institutes of Health.
To create a medical release form, first designate a section at the top of the form that requests the patient’s name, address, date of birth and phone number. Next, include a section that requests the receiving provider or health entity’s name, address, phone number and fax number. Below these sections, create an area that delineates the type of information to be disclosed, including outpatient reports, inpatient summaries, X-ray reports and laboratory tests.
Next, the purpose for the release should be clearly marked. Options include continuation of care, Social Security certification, insurance claim and Worker’s Compensation. None of these fields should be left blank as these are core elements of the release request and failure to include them might delay release requests, according to NIH.
Finally, a release form should include a list of disclaimers and a signature and date line. Authorized disclaimers include the individual’s right to later revoke the authorization to release records, the potential for the information to be re-disclosed by the recipient and not be protected by HIPAA regulations and a notice of any consequences of refusing to sign the release form, states NIH.