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HIPAA Compliant Release Form to Allow Others to See Your Medical Records and Protected Health Information

Massachusetts Department of Public Health

HIPAA (Health Insurance Portability and Accountability Act) is a federal law that  protects the privacy of your medical records and information.  HIPAA limits who your health care providers can share your medical information with, unless you give your permission in writing by filling out an Authorization for Release of Information form. For more information about HIPAA, go to the HIPAA, Frequently Asked Questions section of the U.S. Department of Health and Human Services website,

Sample Authorization for Release of Information

Click here to download a sample, HIPAA compliant form that has been prepared by the Massachusetts Department of Public Health.  By filling out this form and giving it to your health care providers, you are giving them permission to share your medical records with the people or organizations listed on the form.

Click here for another example of a release (prepared by Greater Boston Legal Services.)