Patient release form


What is a patient release form?

A patient release form is a document requesting the release of a patient’s medical records by the patient himself/herself. It gives permission to share the patient’s medical records with a person or an organization. It is often used when a patient needs to transfer to a new healthcare facility. A patient may also wish that a family member or friend be authorized to view their medical records.

Who fills out the patient release form?

The patient release form is filled out by the patient themselves as they are the only individual who can authorize the release of their personal medical records.

What are the components of a patient release form?

The patient release form generally contains personal information about the patient (name, contact number, SSN etc), information about the person or organization to whom the patient intends to release the records to, the information that the patient wishes to share, and a statement indicating that the patient understands the purpose of the release and the potential consequences of signing the form.