FREE · NO SIGNUP · HIPAA COMPLIANT

Free Medical Records Release Form

A universal, HIPAA-compliant authorization for releasing your protected health information. Download the version that fits how you want to complete it. No email required. No account needed. Just download and use.

Cites 45 CFR § 164.508 Works with any provider Three formats No tracking

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FILLABLE PDF

Fill on your computer

Open in Adobe Acrobat, Preview, or any modern PDF reader. Click any field, type your information, save. No printing required if your provider accepts digital signatures.

Download Fillable PDF

PRINTABLE PDF

Print and fill by hand

Flat PDF with clean lines for handwriting. Print, fill in with a pen, sign, and deliver to your provider in person or by mail.

Download Printable PDF

WORD DOCUMENT

Edit in Word or Google Docs

Editable .docx file. Open in Microsoft Word, Google Docs, Apple Pages, or LibreOffice to customize wording, add extra fields, or save filled-in copies.

Download Word File

WHAT IS THIS FORM

A universal HIPAA authorization for releasing your medical records.

A medical records release form (also called a HIPAA authorization) tells one provider that they have your permission to release your protected health information to another party. That party might be another provider, an attorney, an insurance company, a family member, or yourself.

Under the Health Insurance Portability and Accountability Act, your records can only be shared outside a treatment relationship with your written authorization. This form is that authorization. It works with any healthcare provider in the United States because every covered entity is required to honor a valid release that meets the HIPAA requirements.

LEGAL BASIS

This form is structured to satisfy the elements required by HIPAA at 45 CFR § 164.508: a description of the information to be disclosed, the names of the parties releasing and receiving, a purpose, an expiration, your signature, and a notice of your right to revoke. Providers cannot reject a release simply because it isn't on their letterhead.

RELEASE FORM VS. REQUEST LETTER

Are you sure you need a release form?

Two documents do similar-but-different things. Picking the wrong one wastes time. Quick check:

Use a release form when:

RELEASE FORM (this page)

You authorize Provider A to send your records to a third party (another provider, attorney, insurer, family member). The recipient is someone other than you, and the release is the formal authorization for that disclosure.

REQUEST LETTER (in the guide)

You are requesting your own records from a provider, for yourself. Under the Cures Act and HIPAA right of access, you do not need an authorization to get your own records, just a written request. See the six request letter templates.

If you're requesting records to be sent to you personally, the request letters in the guide are simpler. Use this release form when records need to go to someone besides you. For the complete walkthrough of how to get your medical records in every scenario, see our complete 2026 guide.

WHAT'S IN THE FORM

Nine sections, three pages.

Every section is required to satisfy HIPAA. Here is what the form covers:

SECTION 1

Patient Information

Your name, date of birth, address, contact info, and optional verification fields.

SECTION 2

Provider Releasing

The provider or facility that holds the records you want released.

SECTION 3

Recipient

Who should receive the records: another provider, attorney, insurer, yourself, or anyone else.

SECTION 4

Records to Release

Twelve record-type checkboxes plus a date range. Includes ALL records and electronic health information.

SECTION 5

Sensitive Records

Separate checkboxes for mental health, substance use, HIV, genetic, and reproductive records. HIPAA requires specific consent for these.

SECTION 6

Purpose

Why the records are being released: continuing care, personal use, legal, insurance, or other.

SECTION 7

Delivery Method

How you want the records sent: electronically, by email, by mail, fax, or in-person pickup.

SECTION 8

Expiration

HIPAA requires an expiration. Defaults to one year if you don't specify.

SECTION 9

Your Rights & Signature

Plain-language summary of your right to refuse and right to revoke, plus signature lines for patient and personal representative.

HOW TO USE IT

Four steps from download to delivery.

Download the version that fits how you want to fill it out. The fillable PDF lets you type into the form on a computer. The printable PDF is for handwriting. The Word file is for editing if you want to add or change anything before printing.
Complete every section that applies. Patient info, who's releasing the records, who should receive them, what records, what purpose, how to deliver, and when the authorization expires. Skip the sensitive records section unless you specifically want those released.
Sign and date. Sign at the bottom of the form. If you are signing on behalf of someone else (parent, guardian, executor, healthcare power of attorney), complete the personal representative section.
Deliver to the provider releasing the records. Most providers accept release forms by mail, fax, email, in-person delivery, or through their patient portal. HIPAA requires them to act on a valid authorization within a reasonable time, generally 30 days.

Keep a copy for your records. If the provider does not respond within 30 days, you can file a complaint with HHS Office for Civil Rights.

YOUR RIGHTS

What HIPAA gives you.

Right to refuse. No provider can require you to sign a release as a condition of treatment, payment, enrollment, or benefit eligibility (with narrow exceptions for research and eligibility determinations).
Right to revoke. You can revoke this authorization at any time, in writing, by notifying the provider releasing the records. The revocation does not undo any disclosure the provider already made before they received your revocation.
Right to limit. You decide what records are released, to whom, and for how long. Check only the categories you want released.
Right to a copy. Once signed, the provider must give you a copy of the authorization. Keep one for your own records.
Right to know about redisclosure. Once your records are released, the recipient may share them further, and they may no longer be protected by HIPAA. The form explains this.

NOT LEGAL ADVICE

This form is a generic HIPAA-compliant template provided as a free public service. It satisfies the elements required by 45 CFR § 164.508, but some states have additional requirements for releasing certain records (mental health, substance use, HIV). For state-specific guidance see the State Resources directory.