FREE 9+ Sample Records Release Forms in MS Word | PDF

A record release is a written consent from a patient that authorizes a health care provider to obtain and look at the patient’s medical record. The record release may also provide authorization for a child medical release that authorizes emergency medical care or treatment in the event a child or relative gets sick while being away from home. A record release may either mean to check the medical history for medical treatment, or to authorize treatment to a child or relative if any one of them gets sick.

Our Sample Forms for medical release can be downloaded and printed for immediate use by filling up the necessary spaces, or can be used as reference in case users want to make their own medical release forms.

Sample Medical Records Release Form

Authorization for Records Release Form

Dental Records Release Form Example

Records Release Request Form

Blank Records Release Form in PDF

In obtaining a patient’s medical history, it’s very important that a correct diagnosis is actualized when seeking treatment. It’s equally important that medicines being administered on the patient will not react negatively on the body that may have the potential to worsen their condition and could prove fatal. Health care providers cannot just access a patient’s medical history freely without consent. It’s for this reason that a records release form needs to be used to access the medical record.

For those who need to use such forms, you can do this by filling up one of the samples offered here that give permission to the physician or hospital to access your medical history that may be located in another medical facility. You need to supply the necessary information on the form like your date of birth, maiden name (for married females) and Social Security number. You should also write the name of your health care provider or the facility you authorize to access your medical history on the line that indicates authorization to release of medical history.

In writing a records release form, you may want to write a short but detailed summary of your medical history (e.g., any past operations in any part of your body and the medicines you have been taking). This will give your physician or hospital a general idea of your specific medical condition that will be useful in case your condition suddenly deteriorates and you become unresponsive while waiting for your doctor to receive your medical history.

For more examples of records release including those of veterinary uses, please check more on our website or click on the links for Medical Records Release Forms. We also have Release of Information Forms that can be modified or edited after downloading.

Veterinary Records Release Form

Employee Records Release Form

Patient Records Release Form

School Records Release Form

When authorizing a records release, be informed that it is within your legal right to withhold sensitive information you don’t want revealed in your medical condition like sexually transmitted diseases, HIV or AIDS. Information for treatment of alcoholism and drug abuse may also be withheld unless you state otherwise. Withholding these kinds of information may or may not help your condition, but it’s perfectly acceptable and understandable if you want to keep any of those kinds of information private and confidential.

For other examples of different kinds of release forms, please check on our website’s other examples or click on the link for Employee Release Forms. These are all free to download and modify or edit to specifications before printing.