Medical Release Form Template

Top 5+ Medical Release Form Template

What is Medical Release Form?

Medical Release Form is the document which would be filled at the time of patient release from the hospital. It carries the patient full information regarding their health. So in future if the patient face difficulty or any objection raised why patient is released if he is not in good condition. These forms tells the full information why it is release in what condition they released. As you all know that anywhere you go either in hospital or company there will be registration is the first step to enter that place. All these should be done for the security as well as for the information of the person.

It is the form which would be required if you are looking for the sensitive full medical information or confidential information of the patient which is inaccessible to anyone. It should be most important for the research purpose. And also for the legal case to prepare in the defense of the patient.


Medical Release Form

What Constitutes the Medical Release Form?

It is form which generally starts with the authorization of the patient. It states that he/she would be offering his consent regarding the release of their medical information. If the case of patient is minor, then authorization would be coming from the parents or any legal guardian. Then the medical release form states that who would be the recipient as well as who is would be the provider of the clinical information. There are lots of free templates available on the internet. In some forms there is purpose of released is also mentioned.

Medical Release Form
Medical Release Form


Medical Release Form Template

How medical release form should be made

There are types of medical release forms like a release authorizing the medical practitioner to see your medical reports. And another one release that authorizes care of a child or other dependent relative in the injury event or any illness that occurs when you are away from home.


Documents should be prepared to give permission to doctor or hospital to access to your medical history and the records created by any other doctor or any treatment facility. No one can access your medical information without your written permission or consent.

Print your Date of Birth, Social Security Number and maiden name if you have

Then on the piece of paper write “I authorize my release of medical records and my medical history to the” name of the doctor or facility who is requesting your medical reports.

Medical Release Form Template
Medical Release Form Template


You have to write the release of health history so its specific for a certain medical condition or for the specific period of time if you want limited amount of information at the time of release. You have to ensure about some private information it means private information remains private no to share with anyone.

Provided a date at what time you will released and it is valid up to some months like 90 days and after that you have to sign and date of release should be written.


Child Medical Release Template

Children’s Medical Release

You have to give a written statement to your child’s caretaker for permission to seek medical treatment if the treatment becomes necessary. A statement release will protect the caretaker from taking legal actions if your child needs treatment for the sickness or injury or any problem he/she faced to overcome this it will necessary to take the permission from the guardians of the child.

If in case of emergency, I give the consent to the authorize medical care for my child or children.

You must write the name of the person who will be the care taker of your child then write the name of the child or children on the paper.

Child Medical Release Template
Child Medical Release Template


Then you provide a list of the medical conditions that require emergency room. Personnel or medical practitioner should be aware of all the diseases, allergies and more thigs etc.

Provide your full contact details including the address as well as the contact number. So, if the doctor or any facility needs your help, they will contact you. At last you will sign and write the date to allow the medical treatment facility.


Traveling Parents Medical Release

Using Medical Release Form on TRIPS

Like if you are hosting an event or and taking the field trip. Or otherwise put in charge of minor children in the course of your job, you will want a proper permission in case of emergency. In most of the cases if the children join an athletic event or any competition then they will be sent home with the medical release form as a part of the package. This is an especially most important item for the adults in charge to have, in case of an accident, illness or other medical emergency. Without this medical release form, the people caring for your child may not be able to seek medical treatment on his or her behalf. Because the doctor will be afraid to take actions or give treatment to the child.


A medical release form isadocument can be used to take the permission to get the consent to the people in charge to submit your child for an immediate medical treatment on any near hospital or medical practitioner closest to where the event is taking place. Because first aid is necessary to handle the situation. It will not take too much time otherwise it leads to big problem so to protect the person will take permission soon and treatment will start.

It is the authority given from the parents or guardians of the child or children by signing the medical form document. This authority will take their child to conduct lab testing, emergency surgery or other major operations and life-saving measures. It will help doctor to take actions in emergency. So, you see a lot of templates for the medical release form available on the internet.


Generic Medical Release Form

Medical release form is required for everyone because when your accident happen, and you have an insurance for the claim need a medical document. It states about your medical condition. So your claim will be given to you by the insurance company. For example: If you are injured in the car accident and for the claim of your car insurance company you need to provide the medical release form to sue the party for the fault for damages. If you had an accident and your mistake is negligible. So for that you must provide an evidence in the courts. So, form will be told everything about your condition to claim.


Medical release form also used in the criminal case. This can be used to prove the severity of injuries when the person is assaulted. If you are concerning with the medical practitioner, they want a permission from the party being discussed. The medical profession also has strict privacy for the guidelines, and they adhere to. That is why it’s vital to make sure that parties in a case of providingthe medical information by using the medical release form.


When  you go to the hill stations where the oxygen level is less as normal so at that time proper medical check should be done before you go. So it will help you to maintain your health how to handle situation.  If you face any difficulty then your medical form in which whole information is written about your body. So, by this we have to say the medical form is very necessary for everyone either it is a child or old person.



Sometime your medical information’s help other also. If someone needs help like blood, if your health condition is good so you will show your medical release form. Then you provide your blood to someone to save his/her life.


A medical release is an written authorization given for the health providers to release the needed information to the patient as well as someone other than the patient. The federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and laws of states order that health providers not disclose the patient’s information without a valid authorization except in limited circumstances as required or permitted by law.

A simple medical release form will identify all the following basic elements:

  • Who will disclose the patient information and who will receive this information.
  • What information should be disclosed
  • Where will be the important information may be disclosed and re-disclosed by the recipient
  • When will be the authorization expire.
  • Why it is being disclosed (information).
  • How will patient may authorize and revoke the disclosure of information

Release is known by many other names it is stated below:

  • Medical Authorization
  • Authorization to Disclose Health Information
  • HIPAA Release
  • HIPAA Authorization

This information is released by only properly authorized individuals and organization. Because it is often used for the following purpose:

  • Insurance – Insurance companies use this at the time of doing insurance.
  • Continued Treatment – Someone needs a further treatment not handle by hospital in which they admitted. It is shifted to higher facility hospital. So it needs an release from previous hospital.
  • Legal – It works for an accident claim or any assaulted happens.
  • Employer– Medical checkup details will be required by the company at the time of joining company.
  • Research– Information is used in researches