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Medical Record Release Form - Hazelden Betty Ford Foundation

Medical Record Release Form - Hazelden Betty Ford Foundation 2026

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4.4 out of 5

49 votes

The document is an authorization form for patients to disclose their medical records from the Hazelden Betty Ford Foundation and Recovery Partners. It includes sections for patient information, preferred methods of release, facilities, reasons for disclosure, types of information to be shared, and legal disclaimers regarding confidentiality and patient rights.

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Click ‘Get Form’ to open the Medical Record Release Form in the editor.
Begin by entering your Patient Name and Birthdate at the top of the form. If you have other names used during treatment, please include them as well.
Select your preferred method of release by checking one of the options: Mail, Fax, or Flash drive. Specify the facility from which you are requesting records.
Fill in the approximate date of your treatment if known, and provide details about who will receive the information by filling in their Name, Attention, Address, Phone, Fax, and Email Address.
Indicate why you need this information by checking all applicable reasons such as Personal, Insurance, Legal, etc. Then select all types of information you wish to disclose.
Review the confidentiality statements and sign at the bottom of the form. Ensure that all required signatures are included before submitting.

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Versions	Form popularity	Fillable & printable
2018	4.3 Satisfied (57 Votes)
2016	4.4 Satisfied (49 Votes)

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What is a signed medical release form?

A medical records release form is a document that authorizes the release of patient health information from one healthcare provider to a requestor.

How do I fill out a release form?

Some of the crucial information in a release includes: Name of the parties involved, i.e., releasor and releasee. Detailed information about the project. Explicit information of the permissions granted. Any special considerations, including payment obligations or credit, if any. A space for all parties to sign.

How to fill out a records release form?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

What is a medical record release?

A release of information is a document that gives a consumer the opportunity to decide what material they want released from their medical file, who they want it delivered to, how long the data can be issued, and under what statutes and guidelines it is released.

What must be included in a release of information?

Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

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