How to Make a Medical Release Form

Step-by-Step Guide

1. 1

   Step 1: Write a document giving permission to a doctor or hospital to access your medical history and records created by another doctor or treatment facility.

   Doctors cannot access your medical history without your written consent.
2. 2

   Step 2: Type or print your date of birth

   ,, You can also choose make a release for all of your health care information. , Create a section on the paper stating whether you authorize release of your history of sexually transmitted disease, including AIDS or HIV.
   
   Write a second section stating whether you authorize release of treatment for drug or alcohol addiction or mental health treatments. , Write this on the bottom of the release. ,
3. 3

   Step 3: Social Security number

4. 4

   Step 4: and maiden name if you have one.

5. 5

   Step 5: Write on a piece of paper

6. 6

   Step 6: "I authorize release of my medical records and history to..." then name the doctor or facility requesting your medical records.

7. 7

   Step 7: Write your release of health history so it is specific to a certain medical condition or a specific period of time if you want to release only a limited amount of information.

8. 8

   Step 8: Ensure that private information remains private.

9. 9

   Step 9: Write a date specifying an amount of time the release is valid

10. 10

    Step 10: such as 90 days

11. 11

    Step 11: or however long the doctor tells you he will need access to the information.

12. 12

    Step 12: Sign and date the release.

Detailed Guide

About the Author