Individuals
Medical Records Release Authorization
Healthcare authorization allowing sharing of patient medical information between providers, insurers, or family members. Includes scope limitations, expiration dates, and patient consent requirements.
Key Clauses
1
Purpose and Scope
Clearly defines the arrangement, transaction, or service being agreed upon between the parties.
2
Rights and Obligations
Details the specific responsibilities and entitlements of each party under the agreement.
3
Liability and Risk
Addresses assumption of risk, liability limitations, and hold harmless provisions.
4
Payment Terms
Specifies amounts due, payment methods, refund policies, and any additional cost responsibilities.
5
Termination
Establishes conditions and procedures for ending the agreement, including notice requirements.
Use This Template
When You Need This
- Patient switching doctors and needing medical history transferred
- Insurance company requesting records for claim processing or approval
- Specialist physician needing patient's previous test results and treatments
- Patient participating in clinical trial requiring medical history documentation