How to Write a Medical Release Letter
Format your letter., Draft the authorization., State the time period for disclosures., Identify what information to release., Identify how long your authorization is effective., Include other general provisions., Sign the release.
Step-by-Step Guide
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Step 1: Format your letter.
You can set up your letter like a standard business letter.
Make sure to use a font that is readable.
For example, Times New Roman or Arial 12 point works best.
You can address the letter to the doctor or medical provider who maintains the records you want released.
If you are a medical provider, then you might want to draft a form that your patients can use.
Set it up as a template, and insert blank lines for information that will change depending on the patient. -
Step 2: Draft the authorization.
You need to explicitly identify which doctor you are giving permission to release your information.
You also should identify who they should release your medical records to.
You could write: “I authorize Piedmont Medical Practice to use and disclose my protected health information described below to Dr.
Caryn Smith, 2222 High Street, City, Nevada,
12345.” , You should identify what time period of treatment this release relates to.
For example, you could have seen your doctor for the past 10 years, but you only want to release information from the past two years.
You should specify.
Sample language could read: “This authorization for release of health information covers the period of healthcare from August 1, 2013 to April 2,
2016.” Alternately, you could state that your release should cover “all past, present, and future periods.”, You can release all of your medical information or you can release only certain records.
You should specify so that your doctor knows what to release.
If you want to release everything, then include this language: “I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse).”If you only want to release specific records, then you can state exactly what you want released.
Alternately, you could state that you release your complete health history except certain information.
State what information should be held back. , If you don’t give your doctor a date, then they might think the authorization lasts indefinitely.
Accordingly, you should state when it expires, which might be a date or an event.You can write, “This authorization shall be in effect until August 31,
2016.” Or you could write, “This authorization shall be in effect until the date of my surgery.” , You also want to include some general statements about your right to withdraw the authorization and how the information may be used.
This information is particularly important if you are a medical provider who is drafting a template for your patients to use.
Include the following:“I understand I may revoke this authorization in writing at any time.
My revocation is not effective to the extent someone has already acted on my authorization or if my authorization was obtained so that an insurer can contest a claim.” “This medical information may be used by the person I authorize to receive it for medical treatment, consultation, or other purposes as I direct.
I understand that my payment, enrollment, eligibility for benefits, or treatment will not be conditioned on whether I sign this authorization.” “I understand that the information used or disclosed by this authorization may no longer be protected by state or federal law.” , Your release isn’t effective until you sign it.
Accordingly, include the closing words “Thank you” and then include your signature as well as a line for you to print your name.Remember to keep a copy of the release letter for your records.
Hand deliver the release to your doctor or mail it certified mail, return receipt requested. -
Step 3: State the time period for disclosures.
-
Step 4: Identify what information to release.
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Step 5: Identify how long your authorization is effective.
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Step 6: Include other general provisions.
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Step 7: Sign the release.
Detailed Guide
You can set up your letter like a standard business letter.
Make sure to use a font that is readable.
For example, Times New Roman or Arial 12 point works best.
You can address the letter to the doctor or medical provider who maintains the records you want released.
If you are a medical provider, then you might want to draft a form that your patients can use.
Set it up as a template, and insert blank lines for information that will change depending on the patient.
You need to explicitly identify which doctor you are giving permission to release your information.
You also should identify who they should release your medical records to.
You could write: “I authorize Piedmont Medical Practice to use and disclose my protected health information described below to Dr.
Caryn Smith, 2222 High Street, City, Nevada,
12345.” , You should identify what time period of treatment this release relates to.
For example, you could have seen your doctor for the past 10 years, but you only want to release information from the past two years.
You should specify.
Sample language could read: “This authorization for release of health information covers the period of healthcare from August 1, 2013 to April 2,
2016.” Alternately, you could state that your release should cover “all past, present, and future periods.”, You can release all of your medical information or you can release only certain records.
You should specify so that your doctor knows what to release.
If you want to release everything, then include this language: “I authorize the release of my complete health history (including all information related to HIV or AIDS, mental health care, communicable diseases, or treatment of alcohol and drug abuse).”If you only want to release specific records, then you can state exactly what you want released.
Alternately, you could state that you release your complete health history except certain information.
State what information should be held back. , If you don’t give your doctor a date, then they might think the authorization lasts indefinitely.
Accordingly, you should state when it expires, which might be a date or an event.You can write, “This authorization shall be in effect until August 31,
2016.” Or you could write, “This authorization shall be in effect until the date of my surgery.” , You also want to include some general statements about your right to withdraw the authorization and how the information may be used.
This information is particularly important if you are a medical provider who is drafting a template for your patients to use.
Include the following:“I understand I may revoke this authorization in writing at any time.
My revocation is not effective to the extent someone has already acted on my authorization or if my authorization was obtained so that an insurer can contest a claim.” “This medical information may be used by the person I authorize to receive it for medical treatment, consultation, or other purposes as I direct.
I understand that my payment, enrollment, eligibility for benefits, or treatment will not be conditioned on whether I sign this authorization.” “I understand that the information used or disclosed by this authorization may no longer be protected by state or federal law.” , Your release isn’t effective until you sign it.
Accordingly, include the closing words “Thank you” and then include your signature as well as a line for you to print your name.Remember to keep a copy of the release letter for your records.
Hand deliver the release to your doctor or mail it certified mail, return receipt requested.
About the Author
John Powell
Brings years of experience writing about cooking and related subjects.
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