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Free Medical Records Transfer Form

This document provides a form for you to authorize the transfer of medical records from one health care provider to another.

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How to write your Medical Records Transfer Form

 
 
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Reasons to Create

- You have a new doctor or change doctors.
- You move to a new location.
- You need to transfer hospital or nursing home records.
- You need to transfer certain records to a specialist.
 

Before You Begin

Information you may need:
- Name, address, phone number, date of birth, social security number, and any former name of the patient whose medical records are being transferred.
- Name and address of the current health care provider who has the records.
- Name and address of the new health care provider who will be receiving the medical records.
- Name and address of the person requesting the transfer of medical records, if not the patient.
 

Reasons to Update

- You have a new doctor or change doctors.
- You move to a new location.
- You need to transfer hospital or nursing home records.
- You need to transfer certain records to a specialist.
 
 
Document Help
Medical Records Transfer Form

Medical records contain highly private and personal information and are considered confidential. Patients generally have the right to their own medical information and the right to control who else has access to their records. Therefore, with certain exceptions, medical information can only be released with the written authorization of the patient or the patient's authorized representative. This document can be used to provide the necessary authorization. Under rare circumstances, a health care provider may restrict the release of medical records to the patient if the release could be harmful to the patient or others.

Most states recognize that the actual medical records are the property of the health care provider who compiles, stores, and maintains the information. Typically, then, only copies of medical records are released and the health care provider maintains the original record. Providers can charge a fee for copying the records but should not deny the release of medical records because the patient has outstanding medical bills.

Many health care providers have very specific procedures regarding the release of medical records because of confidentiality concerns and the special protection afforded certain types of records such as HIV, mental health, and substance abuse information. Although this form specifically addresses certain types of records, providers may require you to use their specific form to authorize the release of records. Therefore, it is possible that a provider will not honor this program's form.


For More Information:
Disclosure without Consent
Redisclosure
Specially Protected Medical Information
Validity
Who Can Act on Your Behalf
Signing Instructions
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