Free HIPAA-Compliant Release of Information Template

What is a release of information form?

A release of information (ROI) form is a legally required document in which a patient or client authorizes their healthcare provider(s) to disclose their protected health information (PHI) to other specified individuals or organizations. HIPAA (the Health Insurance Portability and Accountability Act) strictly limits when a healthcare provider can share patient information — they must have a patient's explicit, signed authorization to release records to third parties. ROI forms codify this authorization and specify exactly what information is being released, to whom, for what purpose, and for how long the authorization lasts. A properly completed ROI form protects both the patient (by ensuring their information is only shared as they explicitly intend) and the provider (by documenting that the patient authorized the disclosure, protecting against claims of privacy breach). ROI forms are used when a patient wants medical records shared with another provider, when coordinating care across multiple clinicians, when a patient needs records for insurance or disability claims, or when a patient requests their own records. Every healthcare practice must have clear, HIPAA-compliant ROI procedures.

What's in this template

This HIPAA-compliant release of information template includes:

• Patient/Client Identifying Information: Full name, date of birth, address, contact phone and email, medical record number or patient ID if applicable
• Releasing Provider/Organization: Name of the organization or clinician releasing the information, address, phone, fax, electronic portal information if available
• Receiving Provider/Organization: Name and address of the individual or organization authorized to receive the information, relationship to the patient (e.g., "new therapist," "primary care doctor," "insurance company")
• Specific Information to Release: Scope of records authorized (e.g., "all mental health records," "psychiatric evaluation only," "medication management notes," "records from [date] to [date]"); explicit statement of what is NOT being released if applicable; option to specify particular records or date ranges
• Purpose of Release: Why the patient is authorizing the release (e.g., "to continue mental health treatment," "for disability evaluation," "for insurance purposes," "at patient's request")
• Duration of Authorization: How long the authorization is valid (standard is 6 months to 1 year, though patient can specify shorter period), expiration date, statement that patient can revoke at any time
• Patient Signature & Date: Signature of the patient, date signed, and statement that the patient has read and understands the form
• Guardian or Surrogate Signature (if applicable): Signature line for legal guardian, healthcare power of attorney, or surrogate if the patient lacks capacity to sign
• HIPAA-Specific Language: Standard HIPAA-required statements confirming that the patient understands their rights, that information disclosed may be subject to re-disclosure by the receiving provider (if not bound by HIPAA), and that the patient can revoke authorization at any time in writing
• No Release Language (optional): Specific health information the patient does NOT authorize for release (e.g., "do not release HIV status," "do not release substance use treatment records unless absolutely necessary for continuity of care")
• Contact for Revocation: Instructions for how the patient can revoke authorization in writing

When to use this template

Use the release of information form when:

• A patient requests their medical or psychiatric records
• Transferring a patient's care to another provider
• Coordinating care between multiple clinicians or disciplines
• A patient needs records for insurance, disability, or legal proceedings
• A patient is authorizing a family member to access their records
• Responding to a request from another healthcare provider to share patient information
• Creating a standardized ROI process for your practice

This template is used across all healthcare settings: private practice, clinics, hospitals, mental health centers, and all medical specialties. Every practice must have HIPAA-compliant ROI procedures.

How to use the template with Scriber

While the ROI form itself is not typically dictated or transcribed, Scriber can help manage the process of tracking and organizing ROI requests. If you discuss ROI authorizations with patients (explaining privacy rights, what records are available, why they might want to share information with other providers), you can record these conversations with consent and Scriber transcribes them. This creates documentation that you explained the patient's privacy rights and obtained informed consent. Use the transcript to confirm that the patient understood what they were authorizing, then have them sign the ROI form. This approach documents your compliance process while protecting the patient.

Download (free)

This template is available as a printable PDF and editable DOCX file. The form includes all standard HIPAA language required for valid authorization. Customize it with your practice or organization name, adjust scope of information options to match your typical records, and use it as a standard form for all ROI requests. Consult your legal or compliance advisor to ensure it meets your state's specific privacy law requirements (some states have additional requirements beyond HIPAA).

[Download PDF]

Related templates

• Telehealth Informed Consent — Template for documenting patient consent to telehealth services
• SOAP Note Template — Standard progress note format for clinical documentation