Clinical template
Medical Release Form
A medical release is consent to disclose personal health information to someone outside the circle of care — an insurer, a lawyer, an employer, a new clinic the patient names, or a family member who is not a substitute decision-maker. It is not a sick note, not a disability form, and not implied consent to treat.
Blank consent to disclose
Use your clinic letterhead. Keep a signed copy in the chart. If the patient limits the date range or the category of records, honour the limit — do not send the entire CPP because it was easier.
Consent to disclose personal health information
Patient name: DOB: PHN: I, [patient or SDM name / relationship], authorize [clinic / custodian name] to disclose the information below. Disclose to (name of person or organization, address, fax/secure email): Purpose of disclosure (specific): Information to be disclosed (check and describe; do not write 'entire chart' unless that is truly intended): [ ] Visit notes from [date] to [date] [ ] Diagnostic results (lab / imaging) from [date] to [date] [ ] Medication list / allergies [ ] Consult letters specified: [ ] Mental health / substance-use notes (explicitly initialled): [ ] Other: Exclude (if any): This consent is valid until [date] or until withdrawn, whichever is first. I understand I may withdraw consent in writing, except where information has already been released. I understand the recipient may not be bound by the same health-privacy statute as this clinic. Patient / SDM signature: Date: Witness (if your policy requires): Interpreter used: Y/N Copy offered to patient: Y/N
Not a sick note
Work absence, modified duties, and 'please excuse' letters are different documents. Clearance for sport or surgery is a medical clearance form. This page is only authorization to send chart information to a named recipient. Fictional names in the example are teaching material.
PHIPA, PIPEDA, and circle of care
Public hospitals and many clinics operate under provincial health-information statutes (PHIPA in Ontario, HIA in Alberta, and equivalents). Private-sector custodians also have PIPEDA obligations. Details differ by province. The practical split is the same: implied consent often covers sharing among the treating team for care. Express consent is what you need for a third party who is not providing care — insurers, lawyers, employers, schools, media, and relatives who just want a copy.
| Situation | Usual consent | Use this release? |
|---|---|---|
| Send a consult to the specialist you referred, for treatment | Circle of care / implied, if the patient would reasonably expect it | No, unless your policy still wants a signature |
| Insurer or lawyer requests records | Express, written, specific | Yes |
| Employer wants the diagnosis behind a sick note | Express, and usually you send functional limits, not the whole chart | Yes if you are sending chart content; a sick note is a different letter |
| Patient asks you to fax their file to a new FP | Express is safest; many clinics use this form | Yes |
| Spouse wants to 'pick up the results' | Not unless SDM, or the patient named them | Yes, naming that person, or refuse |
Mental health, sexual health, and substance-use notes often need an explicit extra initial. Minimum necessary still applies: if the lawyer asked for the MVA visit and imaging, do not attach five years of unrelated psychiatry. If you are unsure the patient is capable, stop and use the substitute decision-maker rules in your province rather than taking a signature from a confused patient.
What makes the consent usable
- Named recipient, not 'to whom it may concern' and not 'any insurer who asks later'.
- Purpose the patient can understand ('WSIB file 12-345, treatment dates').
- Scope: dates and document types, plus exclusions.
- Expiry, or a statement that it lapses when the purpose ends.
- How to withdraw, and that withdrawal cannot claw back what already went out.
- Signature of the capable patient or the lawful SDM, dated.
A photocopied 'consent' from an insurer that authorizes 'all records, forever, including future visits, to us and our agents' is not something you have to accept as written. Strike the over-broad lines, have the patient initial the scope you will actually send, or use your own form and attach it.
Example — insurer request, limited scope
Clinic release, not a work note
41-year-old, London ON. Disability insurer asked for 'complete file.' Patient limited the release. Fictional.
Patient: Simone T., DOB 1985-02-11 Custodian: Riverside Family Medicine. Disclose to: Great Lakes Disability, claims, [address/fax on file], claim # GL-88421. Purpose: assess short-term disability claim for absence starting 2026-07-14. Information: visit notes and specialist letters from 2026-06-01 to 2026-08-26 relating to lumbar radiculopathy and physiotherapy; MRI lumbar report 2026-07-22; current medication list and allergies. Exclude: unrelated 2024 IUD insertion visit; mental health counselling notes (patient declined to release). Valid until 2026-11-26 or until withdrawn in writing. Patient signed 2026-08-26. Copy given. Staff: do not send the CPP print-all. Do not attach a sick note to this fax unless separately requested and separately written.
After you send
Log what went, to whom, on which date, and the method (fax confirmation, portal). If you withhold a portion because of a professional privilege or a risk of serious harm, follow your statute and document the reason; do not silently omit pages from a release the patient thought was complete. Wrong-fax is a privacy incident — your clinic policy, not this template, governs reporting.
Keep the release separate from the visit note
Scribeberry drafts clinical notes and letters from the encounter. A consent-to-disclose form still needs the patient's (or SDM's) signature and a limited scope. Generate the visit note, then fill the release on your letterhead. Smart Push notes into Accuro, OSCAR, Jane, or any web EMR. Pro is $99/month after the free trial.
Frequently asked questions
What is a medical release form?
Written permission for a health-information custodian to disclose specified records to a named recipient for a stated purpose. In Canada that is express consent under PHIPA, PIPEDA, or the provincial health-information act that applies to you. It is not permission to treat and it is not a sick note.
Do I need a release to send a consult to a specialist?
Usually not when the specialist is in the circle of care for that problem and the patient would reasonably expect the referral. You do need express consent to send the same chart to an insurer, lawyer, employer, or a relative who is not the SDM.
Can the patient limit what we send?
Yes. Date ranges, document types, and exclusions are valid. If the limit makes the disclosure misleading, say so to the patient and the recipient rather than secretly filling the gaps.
Can Scribeberry sign a release for the patient?
No. The patient or SDM signs. Scribeberry can draft related letters and visit notes. Keep the signed release in the chart and send only what it allows.
Templates
