Forms, consent and waiversForm
Medical records release form template
Get a patient's written authorisation before sending their records to someone else: which records, to whom, why, until when, and how they can withdraw their permission. The patient signs on their phone.
Opens in the Salsox editor with 8 signing fields already placed for Patient and Practice. Add their emails and send. The free plan sends 3 documents a month.
Who signs
- Patient
- Practice (you)
Preview
Authorisation to Release Medical Records
Practice: Lakeside Family Medicine, 550 Lakeshore Drive, Burlington, VT 05401, USA
1. Patient
Name: Robert Chen Date of birth: 14 March 1981
2. Recipient
I authorise the practice to release my records to: Dr. Alicia Moreno, Green Mountain Orthopaedics, 75 College Street, Burlington, VT 05401, USA.
3. Records to be released
office visit notes, imaging reports and X-ray images relating to the right knee, from 1 January 2025 to today.
The following especially sensitive information is released only if I write "include" beside it; anything else, or a blank, means it is excluded:
- Mental health records: Answer · Patient
- Substance use treatment records: Answer · Patient
Patient initials confirming these choices: Initials · Patient
4. Purpose
The records are released for: continuing care with a specialist.
5. Delivery
The records will be sent by secure electronic transfer to the recipient's practice.
6. Expiry
This authorisation expires 90 days from the date signed, or when the records have been sent, whichever comes first.
7. Your rights
- You may revoke this authorisation at any time by writing to records@lakesidefm.example. Revoking it does not affect records already released.
- Your treatment, payment or eligibility for benefits does not depend on signing this form.
- Once released, your information may no longer be protected by health privacy law if the recipient is not subject to it.
- You may ask for a copy of this signed form.
Signatures
Patient or legal representative: Signature · Patient Date: Date · Patient Name: Name · Patient
Received for the practice: Signature · Practice Date: Date · Practice
These templates are general starting points, not legal advice. Laws differ between countries and states: check that a template suits your situation, or ask a lawyer, before you rely on it.
About the Medical records release form template
Medical records are among the most protected personal information there is. Before a practice sends them to anyone outside the treating team, such as a new doctor, an insurer, a lawyer or an employer, it usually needs the patient's written authorisation, and the authorisation has to be specific: which records, to whom, for what purpose, and for how long.
This template covers those elements and the statements patient privacy laws commonly require: that the patient may revoke the authorisation in writing, that treatment does not depend on signing it unless the law allows an exception, and that information sent to a recipient who is not bound by health privacy rules may no longer be protected by them. It includes optional check boxes for especially sensitive records, which many laws require to be authorised separately.
The exact requirements differ by country and state, for example under HIPAA in the United States or the GDPR in Europe, so have your privacy officer review the wording once before you use it.
- Signers
- 2
- Signing fields placed
- 8
- Details to fill in
- 11
How to use this template
Open it in Salsox
Choose Use this template. Sign up free if you have no account; the template opens straight after.
Fill in the details
Type your details into each blank, or start from the sample to see how it reads. Save it as your own template to reuse it.
Add signers and send
The editor already has every signature, date and initials field in place. Add each signer's email and send; they sign on their phone, and everyone gets the sealed copy with its audit trail.
Used in
Questions
Can the patient sign on their phone?
Yes. Electronic signatures are generally accepted for authorisations like this, and Salsox records who signed, when and from what device, which supports the record if it is ever questioned.
Can the patient withdraw the authorisation?
Yes, in writing, at any time. Records already sent before the practice received the withdrawal cannot be recalled, as the form explains.
Why are some record types listed separately?
Many laws give extra protection to records about mental health, substance use treatment, HIV status and genetic testing, and require them to be authorised specifically.
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Send it for signature in minutes
Start from this template in Salsox: fill in the blanks, add your signers and send by email, WhatsApp or SMS. Signers sign one field at a time on their phone, and you can collect a payment in the same step.