Release Of Records Request Form

Release Of Records Request Form Template for United States

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Key Requirements PROMPT example:

"I need a Release Of Records Request Form to obtain my complete medical records from Stanford Hospital for the period January 2025 to June 2025, which will be shared with my new healthcare provider in Texas."

Document background

The Release of Records Request Form is essential for accessing personal, medical, educational, or other protected records in the United States. This document is required by federal and state regulations to ensure proper authorization and maintain privacy protections. The form typically includes detailed information about the requestor, specific records being requested, time period covered, and authorization parameters. It's particularly important in healthcare settings where HIPAA compliance is mandatory, but also applies across various sectors including education, government, and financial services. The form serves as documentation of proper authorization and helps organizations maintain compliance with privacy laws while fulfilling record requests.

Suggested Sections

1. Requestor Information: Full identification and contact details of the person requesting records, including legal authority to request if different from subject

2. Subject Information: Full identification details of the person whose records are being requested (if different from requestor)

3. Records Holder Information: Details of the organization/entity currently holding the requested records

4. Records Details: Specific description of records being requested, including type and date range

5. Authorization Statement: Clear statement of permission to release records, including duration of authorization and right to revoke

6. Privacy Notice: Standard privacy notice explaining how information will be used and individual rights

7. Signature Block: Space for signature, date, and witness signatures if required

Optional Sections

1. Purpose of Request: Section detailing why records are being requested (required for medical records, optional for others)

2. Fee Acknowledgment: Section acknowledging any fees associated with the records request and payment terms

3. Delivery Instructions: Specific requirements for how and where records should be delivered

4. Third Party Authorization: Authorization for specific third parties to receive the records

Suggested Schedules

1. Identity Verification Documents: Attached copies of required identification documents

2. Fee Schedule: Detailed breakdown of any applicable fees for different types of records or delivery methods

3. Authorization Documentation: Additional documentation proving right to access records (power of attorney, court orders, etc.)

4. Records Specification List: Detailed list of specific records being requested if too extensive for main form

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Business Associate

Confidential Information

Clauses

Relevant Industries

Healthcare
Education
Financial Services
Government
Employment

Relevant Teams

Legal
Compliance
Medical Records
Human Resources
Information Technology

Relevant Roles

Privacy Officer
Medical Records Administrator
Compliance Manager
HR Manager
School Registrar

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Let's create your Release Of Records Request Form

Authors

Alex Denne

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