How to Write a Medical Records Release Form for Minors: Tips and Examples

Tips: 1. Ensure that the Medical Records Release Form is properly filled out and signed by both the parent or legal guardian and the minor. 2. Make sure to include the medical records that need to be released and to whom the records should be released. 3. Include the date of consent, duration of the release, and any other pertinent information. 4. Make sure to include a statement that the parent or guardian is authorizing the releasing of the medical records. Example: I, [Parent/Legal Guardian Name], hereby authorize the release of my child’s [Minor’s Name] medical records to [Name of Recipient]. These records include, but are not limited to, [list specific medical records]. This authorization is effective as of [date] and will remain valid until [date], at which time it may be revoked. I understand that this authorization may be revoked by me at any time before the expiration date by providing written notice to [Name of Recipient]. Signed, [Parent/Legal Guardian Name] [Date]

Medical Records Release Form for Minors: Sample Templates and Formats

1. Medical Records Release Form for Minors Template [Name of Parent or Guardian] ___________________________ [Address] ____________________________________________ [Phone Number] _______________________________________ [Email Address] _______________________________________ I, [Name of Parent or Guardian], hereby authorize [Name of Healthcare Provider] to release any and all medical records pertaining to my minor child, [Name of Minor Child], to [Name of Recipient]. I understand that this authorization is valid from the date of signature until [Date], unless revoked in writing before that time. I understand that the information being released may include, but is not limited to, medical history, diagnosis, treatment, lab results, x-rays, and other medical information. Signature: ____________________________________ Date: ________________________________________ 2. Medical Records Release Form for Minors Format [Name of Parent or Guardian] ___________________________ [Address] ____________________________________________ [Phone Number] _______________________________________ [Email Address] _______________________________________ To Whom It May Concern: This is to authorize [Name of Healthcare Provider] to release any and all medical records pertaining to my minor child, [Name of Minor Child], to [Name of Recipient]. I understand that this authorization is valid from the date of signature until [Date], unless revoked in writing before that time. I understand that the information being released may include, but is not limited to, medical history, diagnosis, treatment, lab results, x-rays, and other medical information. Signature: ____________________________________ Date: ________________________________________

Common Mistakes to Avoid When Writing a Medical Records Release Form for Minors

1. Not obtaining parental consent: Medical Records Release Forms require parental consent before any records can be released. It is important to always ensure that parents or legal guardians of minors provide written consent before releasing any medical records. 2. Not specifying the type of records to be released: Make sure to specify exactly what type of medical records are to be released, such as lab results, X-rays, physicals, etc., to avoid any confusion and ensure that the right records are released. 3. Not informing the minor of their rights: Include a statement in the form that informs the minor of their rights regarding their medical records, such as the right to inspect and obtain copies of the records, the right to have the records amended, and the right to restrict access to the records. 4. Not including an expiration date: Include an expiration date on the form to ensure that the release of information is only valid for a certain period of time. 5. Not having the form signed and dated: All releases must be signed and dated by both the parent/guardian and the patient (if applicable) in order for the form to be legally binding.