Free HIPAA Release Form — Fill & Print
Create a HIPAA-compliant medical records release authorization in two minutes — fill in the details, print or save as PDF, sign, and send. Compliant with 45 CFR §164.508.
Built in your browser — nothing you type is stored unless you save it to your account.
HIPAA RELEASE FORM
I, ________________ (DOB: ________________), authorize ________________ to disclose my protected health information as described below to ________________.
Information to be released: ________________. Purpose of disclosure: ________________.
This authorization expires: ________________. I understand I may revoke this authorization at any time by notifying ________________ in writing, except to the extent action has already been taken in reliance on it.
I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations (45 CFR §164.508). Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization.
Private by default
The form is generated in your browser. Nothing you type is stored unless you save it to your account — your medical details never touch our servers otherwise.
Accurate extraction
Not a blank PDF to decipher — a guided form that produces a complete §164.508 authorization: who releases, who receives, what information, for what purpose, and when it expires. The elements providers' compliance officers check for.
No templates
Reads any layout — every form comes out as clean, structured rows. Nothing to configure.
Three steps to a clean spreadsheet
Upload your form
Drag in a PDF or image. No account, no setup.
We read and extract
Every line item is pulled into structured rows — the same fields you'd type in by hand.
Download your data
Get a clean CSV free, or Excel and batches with Pro.
From messy PDF to clean rows
A few guided fields
A signed-and-ready authorization
| Field | Value |
|---|---|
| Patient | Jane Cooper (DOB 1985-03-14) |
| Releasing provider | City Medical Center |
| Authorized recipient | Dr. A. Patel, Oak Clinic |
Simple pricing
Free to try. Pick a plan when you need volume.
Anonymous
$0 no signupCreate a form right now.
- Complete HIPAA authorization
- Print / save as PDF
- No account needed
Free account
$0 · registerSave forms for reuse.
- Everything in Anonymous
- Saved forms (24h)
- No credit card
Starter
For steady monthly use.
100 conversions / month
- 100 conversions / month
- Excel (.xlsx) + all export formats
- Batch upload
- Email support
Professional
For professionals and small firms.
300 conversions / month
- 300 conversions / month
- Excel (.xlsx) + all export formats
- Batch upload
- API access
- Priority support
Business
For firms and heavy volume.
1,000 conversions / month
- 1,000 conversions / month
- Everything in Professional
- Team members (linked users)
- Priority support
1 conversion = one document of up to 25 pages. Longer documents count as one conversion per additional 25 pages.
Refer a friend, get 10 free credits
You both get 10 conversion credits when they sign up — no limit.
Questions
What is a HIPAA release form?+
A written authorization (under 45 CFR §164.508) that lets a healthcare provider disclose your protected health information to someone you choose — another doctor, a family member, an attorney, an insurer, or yourself.
What makes it valid?+
Federal rules require specific elements: who's authorized to disclose, who receives, a description of the information, the purpose, an expiration, the right to revoke, and a signature with date. This generator includes every required element.
Do I need a lawyer or notary?+
No — a HIPAA authorization needs only the patient's (or legal representative's) signature. Some providers have their own form and may ask you to use theirs; this one contains the same required elements.
Can I limit what's released?+
Yes — choose complete records, specific date ranges, labs only, imaging only, or billing records only. Narrower scopes are honored; you can also revoke the authorization in writing at any time.
Who can sign for someone else?+
A parent for a minor, a healthcare proxy/POA agent, a legal guardian, or an estate representative for a deceased patient. Sign with your name and note the authority (e.g., 'parent', 'POA').
Is my information private on this site?+
The form is built in your browser — nothing you type is sent to or stored on our servers unless you explicitly save it to an account. Print it and close the tab, and no trace remains.