Free template
HIPAA Authorization for Release of Health Information
A one-page HIPAA release form so family caregivers can receive medical records and speak with a loved one's care team. Download the printable PDF, fill it in, and give a copy to each provider that will release information.
What's included
Patient information
- •Full legal name
- •Date of birth
- •Address
- •Phone
Provider releasing information
- •Provider or organization name
- •Address
- •Phone / fax
Recipient of information
- •Recipient name (caregiver, family member, or provider)
- •Relationship to patient
- •Phone
Records to release
- •Complete medical record
- •Discharge summary, history & physical
- •Lab and imaging results
- •Medication list and prescriptions
- •Consultation and specialist reports
- •Immunization records
- •Mental health, substance use, or HIV records (where allowed)
- •Billing and insurance records
Purpose, expiration & signature
- •Purpose of disclosure (e.g., continuity of care)
- •Expiration date or event (defaults to one year)
- •Signature of patient or personal representative
- •Printed name, date, and relationship if signing as representative
How to use this form
- Download the PDF and print one copy for each provider.
- Fill in the patient, provider, and recipient details.
- Check the specific records you want released.
- Sign, date, and return the form to the provider's medical records office.
This template is provided for convenience and is not legal advice. Some states and record types (mental health, substance use, HIV) may require additional language. Review with your provider or attorney before use.
Keep records organized
Once records are released, upload them to Carebridge Central so the whole family can see medications, appointments, and documents in one calm dashboard.
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