An example of a medical release template includes information about the patient, information about the health care provider and information about who is authorized to receive medical records, explains the Texas Medical Association. Templates specify the record being disclosed and the terms of the authorization.
The terms in a medical release depend on HIPAA and state law, according to the Texas Medical Association. Patients read and sign an authorization acknowledging the release of medical records is voluntary. They sign to indicate how long the authorization remains in effect and that they authorize the release of certain records in their entirety. Templates for medical releases also include a clause stating the patient has the right to revoke the authorization at any time.
After spelling out these terms in the template, the Texas Medical Association suggests asking for the full names of the patients, health care providers and people or entities allowed to view the records. Include information such as dates of birth for everyone involved, addresses and contact information. Specify whether part or all of a medical record is requested. Indicate what type of medical record is being released and the reason for its release. Request signatures from patients, legal representatives and witnesses.
The Law Dictionary points out that no single form exists for medical release templates. Templates need to include all relevant information related to the medical record, with a legal signature from all participants.