Medical Records Release Authorization
Authorize the release of your medical records to a specified recipient.
When to Use This Template
Use this to authorize a healthcare provider to release your medical records to another provider, insurance company, attorney, or yourself. Under HIPAA, providers can share your records for treatment, payment, and their own operations without asking. They need your written authorization before releasing records to most other recipients, such as an attorney, an employer, or an insurer that is not paying the claim.
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[Your Full Name]
[Your Address]
[City, State ZIP]
[Date]
Medical Records Department
[Healthcare Provider / Facility Name]
[Provider Address]
[City, State ZIP]
RE: Authorization to Release Medical Records, Patient: [Patient’s Full Name], Date of Birth: [Patient’s Date of Birth]
Dear Medical Records Custodian:
I, [Patient’s Full Name], date of birth [Patient’s Date of Birth], hereby authorize [Healthcare Provider / Facility Name] to release copies of my medical records to [Recipient Name/Organization], located at [Recipient Address]. My patient identification or medical record number, if known, is [Medical Record Number].
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Important Disclaimer
This template is provided for informational and educational purposes only and does not constitute legal, financial, medical, or professional advice. Every situation is unique. You should consult with a qualified attorney or licensed professional before sending any formal correspondence, especially for matters involving legal rights, government agencies, financial disputes, employment issues, or family court proceedings. Use of this template does not create an attorney-client or professional-client relationship. Formal Letter Templates is not a law firm and does not provide legal services.