How to write a medical release letter

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Writing a Simple Medical Release Letter (with Sample)
Use this sample medical release letter as a template for your formal release letter.
Last updated on January 15th, 2019

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According to the Health Insurance Portability and Accountability Act (HIPAA), patients are allowed to request a copy or summary of their medical records with a medical release letter. They will most probably be charged a fee for this. The fee may vary by state. The medical facility is not required to provide patients with the original documents.

​The more information that is included in a medical release letter, the easier it will be for the records department or doctor’s office to find the reports. Name, address, date of birth, phone number and, if possible, file number. It will also help to include a list of the reports required. ​

For example, blood tests, physical therapy reports, operative reports, hospital stays and imaging studies are a few of the type of records that are in a medical file.

​If possible, the date the test was taken should also be included. The time frame that the patient was receiving treatment or staying in the hospital should also be mentioned.

Notes are also a big part of a person’s medical record. These notes include progress notes, postoperative notes, operative notes, postpartum notes, delivery notes, admission and discharge notes.

​The address where the information is to be sent should be clearly stated. This may be the patient’s home address, another doctor’s office or an insurance company.

Medical Release Form

Most doctor’s offices and hospitals require a medical release form to be filled out and returned to the proper department. This can be obtained before writing the letter and given as an enclosure.

A patient can only request his or her own medical records, and they need not state the reason they want the records. They may not request the records of anyone else without the written permission of that person even if it is a family member. If the person whose records they want is deceased, they need the permission of the next of kin.

The letter should be sent by certified mail. This will give proof to the sender when the letter was sent and that it was received. According to HIPAA rules, the hospital or doctor’s office is allowed 30 days to respond, and they can ask for another 30-day extension if they give a good reason.

​This time limit also varies by state. It is a good idea for patients to look up their state requirements for applying to get their medical records.

Here is a sample letter for release of medical records.

​Medical Release Letter Sample
Date

Applicant’s Name
Applicant’s Address
City, State, Zip Code

Doctor or Hospital’s Name
Address
City, State, Zip Code

RE: Medical identification number and Date of Birth

Dear Doctor’s Name or Hospital Records Department,

I am writing this letter to request copies of my medical records that are in Name of Hospital or Doctor’s Office. I understand that the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations allow me to have these copies.

I received treatment in your facilities from Date, Year to Date, Year. I would like to have copies of all my records that relate to this treatment. This may include the medical history I previously provided to you, consultations with specialists and test results.

I will be happy to pay a fee for copying the records and for postage to send them to the above address.

According to the HIPAA, I can expect to receive my medical records within 30 days. It this is not possible, kindly inform me in writing and tell me when to expect the records.

If you have any questions or require more information, call me at 555 123 4567 or email me at [email protected]

Thank you for your time.

Sincerely,

Signature
Name in print
Medical release form enclosed

The purpose of this letter is to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment.

[Identify records requested, e.g. medical history form you provided; physician and nurses’ notes; test results, consultations with specialists; referrals.]

[Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.]

I understand you may charge a ìreasonableî fee for copying the records, but will not charge for time spent locating the records. Please mail the requested records to me at the above address. [If you request that the records be mailed, you may also be charged for postage.]*

I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*.

[Your signature]
[Your name printed]

*Under HIPAA you can be charged a ìreasonableî fee for copying records. You may also be charged for postage if you ask that records be mailed to you. HIPAA allows 30 days for a provider to respond to your request for records, with one 30-day extension for good reason.

Ensure doctors have permission to treat your child when needed

Adah Chung is a fact checker, writer, researcher, and occupational therapist.

asiseeit / Getty Images

The nature of accidents is that they happen when we least expect them, often at the least convenient times. This is particularly true of accidents and emergencies that involve kids. While these events can be unpredictable or unavoidable, you can still plan for them, specifically by preparing a medical release form for minor children.

Completing a medical release form (also called a medical consent form) ensures that your children will have access to medical care when they need it, even if you can't be reached.

What Is a Medical Release Form?

Medical release forms are a legal way to outline your parental wishes and transfer decision-making authority to your child’s other caregivers when you are unavailable.

The simple form gives clear, irrefutable consent for medical treatment—until you can step in. This makes it possible for your child to get immediate care even if they are not with you, like if they break a bone while with the babysitter or at daycare, or have an allergic reaction while staying with grandma, for example.

These incidents are stressful enough on their own. Without a medical release in place, treatment can be delayed if healthcare providers cannot reach parents or guardians. This is why you should provide a medical consent form to anyone who regularly cares for your child in your absence.

Medical release forms are a vital way for you to ensure that your children are safe and cared for, even when you're not around.

Why It's Important

People often assume that hospitals have to treat everyone who comes through the door, but that's not necessarily true—especially when it comes to children. Many urgent care facilities and emergency rooms will not treat minors unless a parent is present, a parent has given consent in writing, or the child's life is in danger.

Initial screenings will be done at an ER but care will only be provided without parental consent for emergency medical services in cases where a child's life is at risk, according to the American Academy of Pediatrics (AAP).

Consent for treatment is presumed if the child's life is in danger. If your child's injuries or illnesses aren't life-threatening, they might not be able to be treated at an ER or urgent care until you give permission.

For example, without a medical release form in place, if your child were to suffer a possible concussion on the playground while you’re at work or out of town, they would likely have to wait for treatment—including receiving pain relievers for their comfort—until you could be reached.

Medical consent forms fall under the jurisdiction of a healthcare power of attorney. People of all ages can have a POA for health care, but in the case of minors, it affords them seamless access to care by giving their caregivers the power to make crucial medical decisions in your place until you can take over.

Create a Medical Release Form

To ensure your medical consent form contains all the necessary information, consider using a professional template. For example, The St. Louis Children's Hospital offers a free "Permission to Treat" form that you can download and print.

The simple, one-page document includes all of the relevant information caregivers and medical staff would need to treat your children in your absence, including pertinent medical history and insurance information.

You can also download free medical consent forms elsewhere online, such as those from LawDepot and eForms.

Getting Started

Start by compiling all applicable information—including birth dates, medical history, and insurance information—for each of your children. Then, use the steps below to fill out the forms.

  1. Print one or more copies of the medical release form for each child.
  2. Fill out the form completely. Add any specific health information or wishes that you would want caregivers and medical personnel to know.
  3. If you share custody or parenting responsibilities with another person, you will want to include their information as well. Let them know that you're taking this step (and make sure they have a copy of the forms).
  4. Plan to notarize the form to make it legally binding. Wait to sign all copies of the forms until you are in the presence of the notary public (they need to witness the signing of a document in order to notarize it).
  5. Discuss your medical wishes, your child's medical history, how (and when) to use the form, the authority the form grants, and where the forms are filed with all applicable caregivers.

If you share legal custody with your child’s other parent or parents, you will want to arrange to have the form notarized together. Having all of a child’s legal guardians on the form is the best way to indicate that you all give consent for your child to receive treatment if none of you can be reached in an emergency.

Laws regulating how long these permissions remain active vary state by state. Once the covered time period is up, a new medical release form will need to be notarized for a caregiver's authority to make medical decisions to continue.

Considerations

In addition to double-checking that all the information is filled in and correct, there are a few additional steps you should take to ensure your medical consent form works as intended. Firstly, consider having multiple copies notarized for each child. Keep notarized copies (not photocopies of the original) in multiple places.

You'll also want to file a copy at home or your office with your other important documents. Make sure to leave one with caregivers, and anywhere else your child spends time without you (such as school or camp). And make sure to include your primary and secondary insurance information.

Remember to update information (such as a new phone number, new caregiver, or health insurance plan) as soon as it changes. Replace forms when they expire so that everything stays accurate and up to date. Lastly, verify that all of the information on the form, especially phone numbers, is correct.

A Word From Verywell

Having medical release forms completed and stored where you can quickly get your hands on them gives you peace of mind that your kids will have access to medical care should they need it—even if you can't be reached.

Daycare, school, or camp are just a few examples of places where your child likely spends a lot of time without you. The adults looking after them should have copies of your child's medical forms handy and know how to reach you in an emergency.

Check the forms periodically to ensure they're where they should be and that the information is current and accurate.

Below is a sample letter requesting medical records for a hospital in a personal injury accident claim.

Below we also talk a little bit about the challenges in collecting medical records from doctors. You can learn how to obtain your client’s medical records quickly and cheaply here.

Suburban Hospital
8600 Old Georgetown Road
Bethesda, Maryland 20814

ATTN: MEDICAL RECORDS

Our Client: Brian Sequoia
SS No.: 393-29-5763
Date of Birth: March 15, 1977
Date of Accident: April 23, 2021
Date(s) of Service: April 23-28, 2021

Dear Sir or Madam:

My law firm represents Brian Sequoia in connection with injuries he suffered in a motor vehicle crash on April 23, 2021. It is our understanding that our client was seen at your facility for these injuries. He was admitted for two days, suffering from broken ribs, a broken femur, and a closed head injury.

Pursuant to the enclosed HIPAA compliant medical authorization, please provide the undersigned with copies of all records, reports, x-rays and other diagnostic imagery, nurses’ notes, and your prognosis, diagnosis, and treatment plan. Please also send the itemized billing statement for services rendered, including any HICFA forms or UB92 forms.

As you know, Maryland’s Annotated Code, Health General Title, §4-309 requires that you produce these records within twenty-one (21) working days of this request. We would greatly appreciate getting these records as soon as possible.

Make sure you submit a separate request for the medical bills. Most hospitals have different departments for records and bills. Also, make sure you appreciate who all of the health care providers are. Many lawyers assume that going to the ER is one bill. Often it generates 3 or even more bills from different providers within the hospital.

If your efforts fail, as they often do, you need to send a stronger worded letter.

At the time of this writing, we believe our client is no longer receiving medical care from you. If I am wrong about this or Mr. Sequoia has since gone back for further treatment, please contact us so we may discuss sending all of the records at the conclusion of his treatment.

If possible, please fax the records and/or bills to my attention at 410-760-8922. You can also call me at 410-779-4600 if you have any questions or concerns.

If this request has not been sent to the proper custodian, please let us know where we should send the request. Thank you for your time and assistance.

Very truly yours,

Kelli Bowie
Legal Assistant to Laura G. Zois
Enclosure: HIPAA

How to Get the Medical Records from Doctors and Hospitals

You also have to walk a balancing test when you that regard. You cannot alienate the office of the doctor who is going to be the testifying treating doctor in your case.

So you really have to use your judgment in how you approach health care providers who just cannot be bothered to jump on your request for records. Because how you request medical records can have a real impact on the speed at which those documents are delivered.

How to write a medical release letter

In some cases, you need a stronger letter if you don’t have these concerns. This is the letter we use when the sweet call and correspondence fail and this is not a provider you will need help with down the road in the litigation.

If you are a lawyer or paralegal, you need to keep in mind that your client does not understand why it takes so long to get these medical records and the delicate balance in pushing the providers versus the fear of alienating them when you need their help down the road in the case.

Our firm documents every call and every letter to healthcare providers. So if the client is frustrated because we have not gotten the record, it is good to be able to show quick documentation of all of the efforts you have made.

It is also sometimes worthwhile to tell the client that if speed it what they desire, getting medical records is probably the only thing the victim can do faster than the attorneys because the doctors are far more likely to cooperate with the victim who is their patient than the law firm seeking the records.

If the patient wrote a personal letter requesting records, make sure the following patient information was in the original request:

  1. Date of birth.
  2. Name.
  3. Social Security number.
  4. Contact information (address and phone number)
  5. Email address.
  6. Dates of service and specific records requested (tests, discharge notes, etc.)

How do you write a letter requesting a doctor information?

I would like to state that I got admitted/ treatment for ________ (Mention) on __/__/____ (Date). I am writing this letter to request you for issuance of __________ (Inform what record you want). As per hospital guidelines, I request you to issue a copy of my medical records. I need this for ________ (Reason).

How do I request doctor records?

How to Request Your Medical Records. Most practices or facilities will ask you to fill out a form to request your medical records. This request form can usually be collected at the office or delivered by fax, postal service, or email. If the office doesn’t have a form, you can write a letter to make your request.

Can I write my own medical records release?

Unless provided by law, or authorized by you, your doctor, HMO, or other medical provider may not disclose, sell, or otherwise use your medical information for any purpose other than as is necessary for providing direct health care services to you.

What do you write in a letter of request?

What is the format of a request letter?

  1. Sender’s name and contact details, unless shown on a letterhead.
  2. Date of writing.
  3. Recipient’s name and contact details.
  4. Greeting.
  5. Purpose of the letter.
  6. Body of the letter.
  7. Professional closing.
  8. Signature.

How do you write an email asking for something?

  1. Organise the letter clearly into:
  2. Don’t go into too much personal detail when explaining the problem, as this is a formal situation with a person you don’t know well.
  3. To make polite requests use the phrase I would be grateful if you could …
  4. Using nouns instead of verbs can make your writing sound more formal.

How do you write a formal letter?

How to write a formal letter

  1. Write your name and contact information.
  2. Include the date.
  3. Include the recipient’s name and contact information.
  4. Write a subject line for AMS style.
  5. Write a salutation for block style.
  6. Write the body of the letter.
  7. Include a sign-off.
  8. Proofread your letter.

How is letter written?

When writing a letter, you’re ready to greet the person (or business) to whom you’re writing. Skip a space from any addresses you’ve included. Formal letters begin with “ Dear” followed by the name of the receiver. If you don’t have a contact at a certain company, search online for a name, a job title, or department.

How can I get medical records from 10 years ago?

Make a request to the hospital or clinic To make the formal request, you must go to the hospital (or hospitals, if you received several treatments in different health centers) and ask for your old medical records; many of them have a form for this type of process.

Can a doctor refuse to release medical records?

Unless otherwise limited by law, a patient is entitled to a copy of his or her medical record and a physician may not refuse to provide the record directly to the patient in favor of forwarding to another provider.

How far back do my medical records go?

They should keep adult records for at least three years and usually for seven. Most hospitals have records going back longer than seven years, especially if the person has been using services for a long time. The Data Protection Act enables you to ask to see any records which have information about you on them.

Who owns my medical records?

(Health Practitioner (New South Wales) Regulation 2016). You will need to make a written request to the medical practitioner or health organisation. The health provider that created the patient’s records, owns the information.

What do you write in a medical release form?

You should specify so that your doctor knows what to release. If you want to release everything, then include this language: “I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse).”

Is it illegal to ask for medical records?

What CAN’T they Ask? An employer cannot ask a medical professional for an employee’s medical records, or information about an employee’s health, without permission from the employee. Employers cannot request that an employee discloses information about any health conditions that arise during employment.

Spotlight/Common Content: COVID-19 Release of Information office closing

The Michigan Medicine Release of Information office is currently closed to walk-in services. If you have a MyUofMHealth Patient Portal account, you can submit requests for copies of medical records from the portal by using the Medical Record Request form listed under the My Record section.

If you have an urgent need to get copies of your medical records, please call the Release of Information Unit at 734-936-5490 Monday through Friday from 8am – 5pm or fax your request to 734-936-8571.

If you do not have a portal account, follow this link for instructions on how to create a MyUofMHealth Patient Portal account. If you need assistance with account recovery or setting up your portal account, you can call the MyUofMHealth Patient Portal Help Desk at 734-615-0872. The Help Desk is available Monday through Friday 7am – 7pm and Saturday 8am – 1pm.

MyUofMHealth Patient Portal Help Desk

Phone number for patients and staff: 734-615-0872

Hours:

Obtaining Copies of Your Medical Records
Release of Information (ROI)

Records can be released to anyone that the patient authorizes (in writing). A valid authorization MUST contain the following information or the request will be returned:

  • Patient’s full name and date of birth (list any other names the patient may have had
  • Medical Registration Number (MRN) (if available)
  • Specific information being requested (e.g., type of report/information and dates of service, etc.)
  • Purpose for which the information may be disclosed
  • To whom the information is to be sent (name and address)
  • Specify authorization’s expiration date if desired (see ROI form)
  • The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must contain a copy of the guardianship papers or power of attorney
  • Date of the signature.

Requests for medical records of deceased patients require a letter of authority in addition to your signed request. The letter of authority is given to the executor of a person’s estate by the Probate Court upon their death. Releasing records to anyone other than the executor is illegal, as stated in Michigan Court Law 600.2157. Please also include your phone number in case we need to contact you for additional information concerning your request.

Revenue Cycle Mid Service (HIM)
Release of Information (ROI) Unit
3621 S. Street 700 KMS Place
Bay 11 – Mid Service
Ann Arbor, Michigan 48108-1633
Phone: (734) 936-5490
Fax: (734) 936-8571

Use our Medical Records Release Form to allow the release of your medical information to yourself or anyone else who may need it.

Updated November 16, 2020

A medical records release is a written authorization for health providers to release information to the patient as well as someone other than the patient.

The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and state laws mandate that health providers not disclose a patient’s information without a valid authorization except in limited circumstances as required or permitted by law.

  1. When to Use a Medical Records Release Form
  2. Consequences of Not Using a Medical Records Release Form
  3. Common Situations for Using a Medical Release Form
  4. What to Include in a Medical Records Release Form
  5. Medical Records Release Form Sample

1. When to Use a Medical Records Release Form

Patient records are the health provider’s primary business records, but they are also confidential records of information in which disclosure is partially controlled by the patient.

You need this form when releasing information NOT related to the following:

  • Patient’s Medical Treatment
  • Payment for Medical Treatment
  • Healthcare Operations

In addition, health providers have a right to charge for the reasonable costs of copying patient records. Many providers want payment before they will release records. Health IT provides an overview of state law and detail the maximum fees doctors and hospitals may charge patients for copies of records.

Contact the health provider to find out how much the copying charges will be, if any, and include payment with the signed records release. According to a 2005 article published in PubMed Central, “reasonable costs” for copying records range widely from $2 to $55 for short records of 15 pages and upwards of $15 to $585 for longer records of 500 pages.

2. Consequences of Not Using a Medical Records Release Form

Health providers have a duty to ensure that information is released only to properly authorized individuals and organizations. The overarching consequence of not using a release is that the health provider will not release the information. Patients have a right to sue any person who unlawfully releases their information without consent. As a result, health providers will not release any information without a valid records release.

When in doubt about whether a records release is needed, get one signed because it will expedite the release of information.

3. Common Situations for Using a Medical Release Form

A patient’s information is often requested for the following purposes:

Insurance: Insurance companies use the information to underwrite life and health insurance policies, pay bodily injury claims, and pay workers compensation claims.

Continued treatment: When a patient is referred to a specialist or moves and switches health providers, the new provider will want to review the patient’s history.

Legal: In personal injury cases, records provide proof of physical injuries, help calculate damages, and determine the cause of injuries or, in a medical malpractice case, to determine whether the health provider exercised reasonable care.

Employer: In the workplace, employers conduct pre-employment exams and lab tests that relate to specific job requirements, use medical information to determine job fitness, and document sick leave.

Research: Clinical trials and medical studies use identifiable information to conduct research.

Medicinal Marijuana: Your doctor will likely record a need for medicinal marijuana in your records. If a dispensary needs additional proof, this form may need to be provided.

4. What to Include in a Medical Records Release Form

To be valid, a simple records release must include at least the following:

Authorized Request: The names or other specific identification of the person authorized to make the requested disclosure.

Recipient: The names or other specific identification of the recipient of the information.

Specific Information: A description of the information to be used or disclosed, identifying the information in a specific and meaningful manner.

Risk of Disclosure: A statement of the potential risk that information will be re-disclosed by the recipient and no longer protected.

Expiration: Expiration date or expiration event that relates to the patient or to the purpose of the use or disclosure.

Revocation: A statement of the patient’s right to revoke the authorization.

Purpose: A description of each purpose of the requested use or disclosure.

Refusal to Sign: Whether treatment, payment, enrollment, or eligibility of benefits can be conditioned on the authorization and consequences of refusing to sign the release.

Date and Signature: If the patient’s authorized representative signs the release, a description of the authorized representative’s authority to act for the patient must also be provided.

As a reference, a Release is known by other names:

  • Medical Authorization
  • Authorization to Disclose Health Information
  • HIPAA Release
  • HIPAA Authorization

5. Medical Records Release Form Sample

You can use one of our free templates (PDF & Word) to authorize the release of medical records.

Medical Records Release Form

How to write a medical release letter

Alternatively, you can use our document builder to create a complete document.

Below is an example of what a completed medical release form looks like. The patient authorizes the releaser to release his medical information to the receiver because the patient is changing doctors.

How to write a medical release letter

When considering your health, you may also want to choose someone to be your health agent with a medical power of attorney form.

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How to write a medical release letter Preview PDF

How to write a medical release letter

Children’s best friends often become close enough to seem part of the family, and it’s not unusual for families to take these friends with them on family vacations. If you have one of these informally “adopted” kids in your household, you are responsible for the child as if it were your own. When medical emergencies happen, however, you have no legal rights to approve procedures unless you have prior permission from the child’s parents. Doctors have the right to treat children if they are in danger of losing life or a limb, but otherwise the child will have to suffer unless you have a permission form. This form is known as a “consent to treat” or “medical release” form. Neighbors, scout leaders and even aunts and grandparents can benefit from this simple piece of insurance in case of medical emergencies.

Step 1

Download and print one of the consent to treat forms you can find online for this purpose. You can find these forms on almost any general legal site, as well as many of the organizational sites such as those for scouting, church groups and schools. Use the most elaborate and all-encompassing form you can find to cover as many details as possible.

Step 2

Instruct the parents of the child fill out the form in ink, printing legibly. Include the child’s full legal name, any medical information hospital staff should know, such as allergies and prior surgeries, insurance information, the name and number of the child’s physician and your name as the caregiver.

Step 3

Take the form, along with your photo ID, to a notary public, accompanied by the parent of the child. If the parents of the child are married, only one parent is needed. If the parents are divorced, it must be the custodial parent. Both of you should sign the form in front of witnesses, which the notary can often provide. Have the notary sign and seal the form to signify that your signature is real.

Step 4

Place the form in a folder or envelope and keep it in a safe place. When you are traveling with the child, keep the form in your wallet or with your other important papers.

This must be done on the basis of an explanation by a clinician.

Consent from a patient is needed regardless of the procedure, whether it’s a physical examination, organ donation or something else.

The principle of consent is an important part of medical ethics and international human rights law.

Defining consent

For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.

The meaning of these terms are:

  • voluntary – the decision to either consent or not to consent to treatment must be made by the person, and must not be influenced by pressure from medical staff, friends or family
  • informed – the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead
  • capacity – the person must be capable of giving consent, which means they understand the information given to them and can use it to make an informed decision

If an adult has the capacity to make a voluntary and informed decision to consent to or refuse a particular treatment, their decision must be respected.

This is still the case even if refusing treatment would result in their death, or the death of their unborn child.

If a person does not have the capacity to make a decision about their treatment and they have not appointed a lasting power of attorney (LPA), the healthcare professionals treating them can go ahead and give treatment if they believe it’s in the person’s best interests.

But clinicians must take reasonable steps to discuss the situation with the person’s friends or relatives before making these decisions.

Read more about assessing the capacity to consent, which explains what someone can do if they know their capacity to consent may be affected in the future.

How consent is given

Consent can be given:

  • verbally – for example, a person saying they’re happy to have an X-ray
  • in writing – for example, signing a consent form for surgery

Someone could also give non-verbal consent, as long as they understand the treatment or examination about to take place – for example, holding out an arm for a blood test.

Consent should be given to the healthcare professional responsible for the person’s treatment.

This could be a:

  • nurse arranging a blood test
  • GP prescribing new medication
  • surgeon planning an operation

If someone’s going to have a major procedure, such as an operation, their consent should be secured well in advance so they have plenty of time to understand the procedure and ask questions.

If they change their mind at any point before the procedure, they’re entitled to withdraw their previous consent.

Consent from children and young people

If they’re able to, consent is usually given by patients themselves.

But someone with parental responsibility may need to give consent for a child up to the age of 16 to have treatment.

When consent is not needed

There are a few exceptions when treatment may be able to go ahead without the person’s consent, even if they’re capable of giving their permission.

It may not be necessary to obtain consent if a person:

  • needs emergency treatment to save their life, but they’re incapacitated (for example, they’re unconscious) – the reasons why treatment was necessary should be fully explained once they have recovered
  • immediately needs an additional emergency procedure during an operation – there has to be a clear medical reason why it would be unsafe to wait to obtain consent
  • with a severe mental health condition, such as schizophrenia, bipolar disorder or dementia, lacks the capacity to consent to the treatment of their mental health (under the Mental Health Act 1983) – in these cases, treatment for unrelated physical conditions still requires consent, which the patient may be able to provide, despite their mental illness
  • needs hospital treatment for a severe mental health condition, but self-harmed or attempted suicide while competent and is refusing treatment (under the Mental Health Act 1983) – the person’s nearest relative or an approved social worker must make an application for the person to be forcibly kept in hospital, and 2 doctors must assess the person’s condition
  • is a risk to public health as a result of rabies, cholera or tuberculosis (TB)
  • is severely ill and living in unhygienic conditions (under the National Assistance Act 1948) – a person who’s severely ill or infirm and living in unsanitary conditions can be taken to a place of care without their consent

Consent and life support

A person may be being kept alive with supportive treatments, such as lung ventilation, without having made an advance decision, which outlines the care they’d refuse to receive.

In these cases, a decision about continuing or stopping treatment needs to be made based on what that person’s best interests are believed to be.

To help reach a decision, healthcare professionals should discuss the issue with the relatives and friends of the person receiving the treatment.

They should consider:

  • what the person’s quality of life will be if treatment is continued
  • how long the person may live if treatment is continued
  • whether there’s any chance of the person recovering

Treatment can be stopped if there’s an agreement that continuing treatment is not in the person’s best interests.

The case will be referred to the courts before further action is taken if:

  • an agreement cannot be reached
  • a decision has to be made on whether to stop treatment for someone who’s been in a state of impaired consciousness for a long time (usually at least 12 months)

It’s important to note the difference between stopping a person’s life support and taking a deliberate action to make them die.

For example, injecting a lethal medicine would be illegal.

Complaints

If you believe you have received treatment you did not consent to, you can make an official complaint.

has retained this law firm/office with respect to injuries sustained as a result of an accident on the above-referenced date. In order to handle this properly, we are requesting copies of the following:

  • All records, cover-to-cover, in your file/chart from the date of the subject accident to the present date.
  • Itemized statement showing all charges for all services from the date of the subject accident to the present date.

Enclosed, please find a signed HIPAA release authorization form that allows this firm to receive the requested information. Please forward this information to us at your earliest convenience. Faxed copies are acceptable.

If you require prepayment, please send an invoice for prompt payment.

Thank you for your assistance in this matter.

Locations
Phoenix, Arizona

602-ARIZONA (602-274-9662)
2394 E Camelback Rd #600
Phoenix , AZ 85016 602-274-9662 0

Denver, Colorado

303-800-8888
1700 Lincoln Street #2400
Denver , CO 80203

Las Vegas, Nevada

702-625-7777
300 S. 4th Street #1400
Las Vegas , NV 89101

Nogales, Arizona

520-394-4733
420 West Mariposa Road, Suite 200
Nogales , AZ 85621

Tucson, Arizona

520-477-7777
1 S Church Ave #1000
Tucson , AZ 85710

Chicago, Illinois

312-757-7777
141 West Jackson Boulevard #4219
Chicago , IL 60604

We’re asking for your help to reduce the amount of paper requests we receive. Please refrain from submitting your forms by mail. Instead, please send them by email or fax them to 503-215-0405. Thank you.

Providence Health & Services is required by law to maintain the privacy of your health information, to provide you with a notice of our legal duties and privacy practices, and to follow the information practices that are described in the Notice of Privacy Practices.

You have the right to receive a copy of your health information that we maintain, with some limited exceptions. You have the right to receive a copy of your health information in a format you prefer (e.g., paper, email, CD, fax, MyChart). You have the right to request that your health information be sent to any person or entity.

Obtain your medical records via MyChart

Patients can obtain copies of electronically-maintained records at no charge directly from your MyChart account. The MyChart secure web portal allows patients to view portions of their medical record, send a message to their care team, view and pay bills, and request copies of medical records.

To sign up for a MyChart account:

Request access, authorize disclosure via forms or in writing

To receive a copy of your health information, you may complete the Patient Request for Access form, you may write a letter, or if you prefer, you may use the Authorization for Disclosure form:

Formularios para autorización para liberar información de salud

If you choose to write a letter, it must include the following required elements:

  • Signed by the individual (patient)
  • Clearly identify the patient, preferably name and date of birth
  • Clearly identify the person designated to receive the records
  • Identify what records are to be included

How to submit your request

For hospital records:

Providence Oregon Central ROI
PO Box 4950
Portland, OR 97208
Phone: 503-215-7423
Fax: 503-215-0405
Send an email

For clinic records:

Everett Central ROI
PO Box 1147
Everett, WA 98206
Phone: 425-317-0735
Fax: 920-406-3763
Send an email

Processing time

Please allow sufficient time for processing. Turnaround time varies according to state law:

  • Oregon: up to 30 days
  • Montana: up to 10 days

For medical use, there is no fee if records are to be sent directly to a doctor or other healthcare provider for the purpose of continuing care.

For copies for patients or their representatives, there may be a reasonable, cost-based fee.

For copies for other uses, the current rates set by state law may apply.

Payment

Please follow the payment instructions on the invoice you receive with the records.

Amendment request

You may write a letter or complete this form to request a correction to your protected health information that was originated or created by a Providence physician.

Accounting of disclosures request

You may write a letter or complete this form for an accounting of disclosures of your protected health information by Providence Health & Services.

Restriction or revocation request

You may write a letter or complete this form to restrict the release of your protected health information, revoke a previously signed authorization, or to opt out of Care Everywhere.

Language services

Providence provides free language services to people whose primary language is not English.

Gathering the appropriate medical records is the key to putting together a solid medical malpractice case. The history of how you were treated, who treated you when, how your medical profile changed, and other factors will ultimately determine who (if anyone) is liable for any injuries you may have sustained. Your attorney will help you compile the necessary information to build a strong case, but it’s always a good idea to be prepared before you step foot in your attorney’s office.

Contact a medical malpractice attorney near you if you have specific questions about a malpractice claim or require legal assistance. Visit FindLaw’s Medical Malpractice Legal Help section to learn more about working with an attorney.

HIPAA and the Privacy of Medical Records

To share your confidential medical information, you will be required to sign a medical records release form. Health care providers and insurers are required by law to keep your medical records and health information strictly confidential, with an emphasis on making sure personally identifiable data is protected. The Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, codified these requirements. The release form is essentially a waiver from liability under HIPAA.

Types of Medical Records

Even if your injury is physical in nature, your attorney also may ask for mental health records. You may have an additional claim for pain and suffering, or perhaps the medication you were taking for a mental illness interacted with another drug, causing your injury. It’s best to err on the side of providing too much medical information. Other types of records that could be relevant to your case include prescription drug information, insurance information, medical invoices, and similar documentation.

In addition to medical records, your lawyer will ask for evidence of lost wages or any additional costs or hardship related to the injury. Some health insurance policies cover lost wages or profits (if you are a business owner), but your attorney will have to prove that any wage loss or time off was caused by the injury.

Sample Medical Release Form

In any event, your attorney will need you to sign a release form like the one below so that your medical providers are authorized to provide a copy of your records to your lawyer. See FindLaw’s Medical Malpractice section for more articles and resources.

HIPAA Privacy Authorization Form

Patient’s name _____________________________________________

Date of birth ____/____/____

Social Security Number ______-___-_______

Telephone number (____) ____-_______

At my request, I authorize the following healthcare provider to use and disclose the protected health information described below.

Name of provider __________________________________________Provider’s address ________________________________________________________________________________________________________________________________________________________________________

[ATTORNEY’S NAME AND ADDRESS HERE]

This authorization for release of protected health information covers the following period, from:

____________________ to ____________________ .

Extent of Authorization:

Please release all my complete health record information, with the exception of the following:

Expiration of Authorization:

This authorization shall be effective until _________________ (date), after which this authorization expires.

I understand that I am permitted to revoke this authorization in writing at any time.

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE.

Patient’s Signature:___________________________________________ Date: _______________________

Contact an Experienced Medical Malpractice Attorney

A qualified medical malpractice lawyer will help you amass all the necessary documentation for a successful case. Finding the right attorney can mean the difference between receiving compensation and walking away empty-handed. A good first step is to get a claim evaluation from a medical malpractice attorney.

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Medical Forms

In an emergency, you may not be able to tell your care providers about your complete medical history or you may be unavailable if your child needs attention in the emergency department of your local hospital. These forms are here to help you get the care you need in a life-threatening situation.

Emergency Information Form for Children with Special Health Care Needs
ACEP and the American Academy of Pediatrics offer parents of children with special health care needs an Emergency Information Form – a tool to transfer a child’s complicated medical history and critical information in the event of an acute illness or emergency injury.

Personal Medical History
If you or a member of your family has a medical emergency, the physician will need a complete medical history. Complete this form (don’t forget to update it) and keep it in an easily accessible place. This form is convenient to use while you’re traveling.

Consent to Treat Form This Consent to Treat Form gives a physician permission to treat your child when he or she is in someone else’s care. Complete it and make sure grandparents and babysitters have access to it.

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Federal law [5 USC 552a(b)] requires that all requests for records and information be submitted in writing. Each request must be signed (in cursive) and dated (within the last year). Requests for certain types of restricted records require specific authorization from the veteran or person of record. You will be notified if this type of authorization is required and may receive NA Form 13036, Authorization for Release of Military Medical Patient Records.

As the NPRC files most clinical records and medical treatment records by the name of the last hospitalizing or treatment facility, requesters must provide the following information:

  1. Name and Location of the last hospitalizing (inpatient clinical records) or treatment facility (outpatient health records): usually this is the last facility at which treatment was provided.
  2. The Year of hospitalization or last treatment and the Type of treatment (inpatient, outpatient, dental, mental health, etc.). If you need copies of specific records, please be sure to state the type of illness, injury or treatment involved.
  3. The patient’s Full Name used during treatment.
  4. The patient’s Social Security Number and Status (specify: veteran, retiree, dependent of military, federal employee or other) during treatment.
  5. If the patient is/was a dependent: the Military Sponsor’s Name and the Sponsor’s Service Number and/or Social Security Number.

Note: If you filed a medical-related claim with the Department of Veterans Affairs, your clinical (inpatient) records may be on file with that agency.

To request clinical and medical treatment records:

Veterans and Next-of-Kin may:

All Others (including veterans and next-of-kin who choose not to submit an electronic request):

When sending a request via postal mail or fax, please use the Standard Form (SF) 180, Request Pertaining to Military Records. Although not mandatory, using the SF-180 is the recommended method to send a request for military service information. This form captures all the necessary information to locate a record. Provide as much information on the form as possible and send copies of any service documents that you may have.

Follow the instructions for preparing the SF-180. Check the Records Location Table and submit your request to the appropriate address.

Costs: Generally there is no charge for basic military personnel and health record information provided to veterans, next-of-kin and authorized representatives. If your request involves a service fee, you will be notified as soon as that determination is made.

Response Time and Checking the Status of a Request:

Response time varies and is dependent upon the complexity of your request, the availability of records and our workload.

Checking the Status of Your Request: Once you have allowed sufficient time for us to receive and process your request, you may check the status of your request by using the Online Status Update Request form.

Special Note on Calling by Phone: If you have already submitted a request and need to know its status you may speak to a Customer Service Representative. Staff is available to take your call as early as 7:00 am CST and as late as 5:00 pm CST. Our peak calling times are weekdays between 10:00 am CST and 3:00 pm CST: Telephone: 314-801-0800 Telephone (Toll Free) 1-866-272-6272

General Information:

Veterans and Next-of-Kin of deceased veterans have the same access rights to the record. The next-of-kin is defined as any of the following: the un-remarried widow or widower, son, daughter, father, mother, brother or sister of the deceased veteran. Next-of-kin must also provide proof of death of the veteran, such as a copy of the death certificate, a letter from the funeral home or a published obituary.

Authorized Third Party Requesters, e.g., lawyers, doctors, historians, etc., may submit requests for information from individual records with the veteran’s, or next-of-kin’s, signed and dated authorization. They should state who they are in relation to the individual and the purpose of the request. All authorizations should specify exactly what the veteran (or next-of-kin) is allowing to be released to a third party. Authorizations are valid one year from date of signature. A sample authorization is included for your review. Next-of-kin must also provide the third party requestor with proof of death of the veteran, such as a copy of the death certificate, a letter from the funeral home or a published obituary.

Information or copies of documents may be released from military and medical records within the provisions of the law. The Freedom of Information Act (FOIA) and the Privacy Act provide balance between the right of the public to obtain information from military service records and the right of the former military service member to protect his/her privacy. Please review these items for additional information. In all cases, you must sufficiently identify the person whose record is requested, so that the records can be located with reasonable effort.

This page was last reviewed on January 20, 2022.
Contact us with questions or comments.

A signed HIPAA release form must be obtained from a patient before their protected health information can be shared with other individuals or organizations, except in the case of routine disclosures for treatment, payment or healthcare operations permitted by the HIPAA Privacy Rule. Releasing medical records without a HIPAA authorization form is a HIPAA violation.

Summary of the HIPAA Privacy Rule

The HIPAA Privacy Rule (45 CFR §164.500-534) became effective on April 14, 2001. The primary purpose of the HIPAA Privacy Rule is to ensure the privacy of patients is protected while allowing health data to flow freely between authorized individuals for certain healthcare activities.

The HIPAA Privacy Rule allows HIPAA-covered entities (healthcare providers, health plans, healthcare clearinghouses and business associates of covered entities) to use and disclose individually identifiable protected health information without an individual’s consent for treatment, payment and healthcare operations. In all cases, when individually identifiable protected health information needs to be disclosed, it must be limited to the ‘minimum necessary information’ to achieve the purpose for which the information is disclosed.

The Privacy Rule also gives patients the right to access the health data created, stored or maintained by their healthcare providers. Patients are permitted to obtain the data in a covered entity’s designated data set – a group of records maintained by the covered entity that is used to make decisions about a patient’s healthcare. Patients are also permitted to amend certain information held by a covered entity if it is discovered to be incorrect. Such requests should be obtained from a patient in writing.

Covered entities are not required to obtain consent from patients for routine disclosures for treatment, payment or healthcare operations, although some covered entities still choose to do so. This provides them with an additional level of protection in the event of a privacy complaint or audit.

Such authorizations detail when protected health information will be used by the covered entity, the entities to which that information will be disclosed, and the circumstances under which information will be used and disclosed. Essentially, such an authorization duplicates much of what is detailed in a covered entity’s Notice of Privacy Practices.

When is a HIPAA Authorization to Release Medical Information Form Required?

A HIPAA release form must be obtained from a patient before their protected health information is disclosed for any purpose other than those detailed in 45 CFR §164.506, which are specifically covered in 45 CFR §164.508 and summarized below:

  • Prior to the disclosure of PHI to a third party for reasons other than the provision of treatment, payment or other standard healthcare operations – E.g. disclosing information to an insurance underwriter
  • Prior to PHI being used for marketing or fund-raising purposes
  • Prior to PHI being provided to a research organization
  • Prior to psychotherapy notes being disclosed
  • Prior to the sale of PHI or sharing that involves remuneration

What Information Should be Detailed on a HIPAA Release Form?

A HIPAA-compliant HIPAA release form must, at the very least, contain the following information:

  • A description of the information that will be used/disclosed
  • The purpose for which the information will be disclosed
  • The name of the person or entity to whom the information will be disclosed
  • An expiration date or expiration event when consent to use/disclose the information is withdrawn. For example, an expiration event may be when a research study is completed
  • A signature and date that the authorization is signed by an individual or an individual’s representative. If a representative is signing the form, the relationship with the patient must be detailed along with a description of the representative’s authority to act on behalf of the patient.

The HIPAA release form must also include statements that advise the individual of:

  • Their right to revoke their authorization
  • Any exceptions to the individual’s right to revoke the authorization
  • Details of how the authorization can be revoked
  • To the extent that an individual’s right to revoke authorization is included in the notice required by § 164.520 (Notice of Privacy Practices)
  • That the covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization
  • That there is potential for information disclosed under the terms of the authorization to be redisclosed by the recipient and no longer protected by 45 CFR Part 164, Subpart E

A HIPAA release form must be written in plain language and a copy of the signed form should be provided to the patient.

Do you need a copy of your medical records?

Then you need a HIPAA Release Form

eForms can help!

Follow the simple process, automatically generate the form.

Do you need a copy of your medical records?

Then you need a HIPAA Release Form

eForms can help!

Follow the simple process, automatically generate the form.

About HIPAA Journal

HIPAA Journal provides the most comprehensive coverage of HIPAA news anywhere online, in addition to independent advice about HIPAA compliance and the best practices to adopt to avoid data breaches, HIPAA violations and regulatory fines. HIPAA Journal’s goal is to assist HIPAA-covered entities achieve and maintain compliance with state and federal regulations governing the use, storage and disclosure of PHI and PII.

How to write a medical release letter

As a public safety officer, you put your life on the line each day to ensure our safety. By doing so, you understand that sustaining an on-the-job injury is always a possibility. If you happen to be among those in your same profession who have filed a Workers’ Compensation claim, you’ve undoubtedly received a blank medical release of information form from your employer’s insurance adjuster.

Don’t be fooled by such a request for your signature on a medical records release form that leaves the doctor/facility entry blank. You are not required to complete such a doctor release form.

Workers’ Compensation Authorization for Release of Medical Records

How to write a medical release letter

In order to discover prior injuries or pre-existing conditions, the adjuster will try to use a blank medical release form to acquire all your medical records from every doctor you’ve ever seen, even if those records are entirely irrelevant to your Workers’ Compensation injury.

"However, this doesn’t mean that the insurance company does not have a right to obtain relevant records in your case," explains David Goldstein, a co-managing partner with Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP (GEK). "They are legally allowed to do so once you have filed a claim. And, the sooner they have the relevant records to review, the sooner they can make a determination on whether they will accept your claim. The key here, though, is relevant records; they can’t go on a hunting expedition."

HIPPA Privacy Authorization Form

When it comes to authorization for release of medical records, the Health Insurance Portability and Accountability Act (HIPAA) sets forth federal regulations that govern disclosure of such records, including the essential features of a valid medical disclosure authorization form. These "core elements" include the following:

  • A description of the information to be disclosed and the purpose for the disclosure.
  • A particular expiration date upon which the disclosure form becomes invalid.
  • The name of the person to whom the disclosure may be made.
  • The name of the doctor or facility authorized to disclose the information.

HIPPA Violations and Workers’ Compensation

How to write a medical release letter

As outlined by HIPAA, an authorization is not valid if it has not been filled out completely. "It must include the particular doctor or facility authorized to release records. Writing in the doctor or facility after you’ve signed the disclosure form is illegal.

"In addition, a medical facility is not legally permitted to disclose protected health information unless the authorization form is valid.

“HIPAA clearly states that a doctor or medical facility may not disclose protected health information without an authorization that is valid." In other words, even if an injured worker signed the blank medical record release form, the insurance company could not (legally) acquire any medical information with it.

Falsifying a medical authorization form by adding the doctor/facility name after the form has been signed is a crime under federal law; if prosecuted and convicted, an insurance adjuster that does so can be subject to a fine of up to $250,000 and/or imprisonment for not more than 10 years. Even though the law is clear regarding using such blank forms, and there are severe penalties for violating it, insurance companies continue this practice.

Legal Guidance in Release of Medical Records

"You are not required to complete such a blank form, but it is imperative that you communicate your objection to it so there is no adverse effect on your case. Unfortunately, if you’re not represented by an attorney, failing to sign one of these release forms can result in the denial of your claim."

The attorneys at GEK have more than 30 years of experience fighting for Justice for the Injured®. If you would like to speak to a GEK attorney about your legal options, including the appropriate release of your medical records, please call 213-739-7000 or click here.

We are here to provide you with your medical records, and strive to fulfill your request timely while ensuring your privacy. The following information will help guide you in the options available and provide FAQs and contact information if you have any questions.

Get the help you need

Quick Links

Obtaining Your Medical Records

Option 1: Request medical records via your myUCLAhealth account

If you have not signed up for myUCLAhealth, go to How to Sign Up for myUCLAhealth for instructions.

  1. Log in to myUCLAhealth portal
    (Request for medical records can only be accessed via PC, mobile devices are not supported at this time)
  2. Follow instructions using links below:

For assistance with your myUCLAhealth account, call 855-364-7052.

Option 2: Download and print the authorization for Release of Health Information form.

  1. Download and print the authorization form for Release of Health Information for Patient or a third-party (i.e. Non-UCLA Provider, Insurance Company, Attorney, etc.).
  2. Complete and sign the form.
    Please Note: electronic signatures are not accepted at this time.
  3. Submit completed form via email, fax, or mail.
    Email:[email protected]
    Fax: 310-983-1468
    Mail:
    UCLA Health
    Health Information Management Services
    10833 Le Conte Ave., CHS, BH-902
    Los Angeles, CA 90095

Medical Record Copy Fee

UCLA Health will invoice you for the production of records, and will invoice you by mail/email. Please see our Frequently Asked Questions.

Contact Information

Business Hours: 8:00 am to 4:30 pm, Monday to Friday
Phone: 310-825-6021
Fax: 310-983-1468
Email: [email protected]
Mailing Address:
UCLA Health
Health Information Management Services
10833 Le Conte Ave., CHS, BH-902
Los Angeles, CA 90095

STAT Request

(For physicians and hospital use only)

If you are a physician or hospital and your request is urgent, please fax your request to 310-206-4831.

If you are requesting additional information such as radiology imaging, pathology slides, or billing information, please contact the corresponding department below directly:

Why do I need a Medical Release Form?

Player Medical Releases

Why do I need these?

Each season you will receive a medical release for each player on your team.

Parents need to sign the bottom of their child’s medical release! (if the signature was not done electronically)

You will keep the signed releases. If for any reason an injury occurs and the parent is not in attendance to take care of the child, this release will help you contact the appropriate person. Or if you need to accompany the child to a doctor, ambulance, or hospital facility, you will have the appropriate paperwork giving consent for medical treatment of the injured player.

Example Release Below: How to write a medical release letter