Replace your inefficient paper release of information forms using our free HIPAA release form.

This template enables you to provide patients with an easy-to-use digital form when requesting their prior medical records be released to a new practice or themselves. It includes sections to gather practices’ information on both ends – the old practice the information is being sent from and the new practice it needs to be sent to. It also includes a section for patients to specify which information is authorized to be released.

All data collected can be made HIPAA compliant with our Enterprise plan after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure at rest and in transit.

In addition to the patient-facing sections, there is an internal section for your employees to interact with each entry after being submitted. This section enables employees to keep track of whether the request has been sent to the appropriate party yet or if a PDF version has been uploaded into the patient’s medical file for future reference. Within this section includes fields that automatically collect the name and email address of the employee who completed the task, if they are logged into their own Cognito Forms account. Using our Entries page and workflow statuses, your staff can easily keep track of the status of each request throughout the process.

Easily customize the template for your practice by adding, removing, and editing fields to fit your needs. Some noteworthy additions are:

• Quickly brand it with your logo and style using our Organization Theme feature
• Easily embed the form onto your website, so your patients don’t have to leave your site to complete their request
• Automatically send copies of the request to your EMR/EHR using an integration with Make, Microsoft Power Automate, Zapier, or webhooks