Standard Forms
As a convenience to our clients, we endeavor to include the most frequently used record retrieval forms for facilities. Because forms change from time to time, and often change with little notice, please always refer to the regulations and guidelines for your jurisdiction to ensure the most up-to-date forms are utilized.
National Forms
- HIPAA Release
- Social Security Administration Consent for Release of Information (Form OMB No. 0960-0566)
- Medicare & Medicaid Authorization (Form OMB No. 0938-0930)
- Department of Veterans Affairs Authorization for Release of Military Medical Patient Records (Form OMB No. 3095-0039)
- Department of Veterans Affairs Request for and Authorization to Release Health Information (VA Form 10-5345)
- Internal Revenue Service Request for Copy of Tax Return (Form 4506)
- Internal Revenue Service Request for Transcript of Tax Return (Form 4506-T)
California Forms
- California Department of Health Care Services HIPAA Forms (Northern California)
- California Department of Industrial Relations Request for DWC Authorization Number
- Kaiser Permanente Authorization for Release and/or Disclosure of Medical Information
- Kaiser SoCal Authorization
- Los Angeles Fire Department EMS Records Custodian Authorization for Release of Protected Health Information
- Stanford Health Care (SHC) Authorization for Use or Disclosure of Protected Health Information
- Workers Comp
- Employment Development Department (EDD) State of California Authorization for Release of Records (Form DE 5600 (3-10))
Michigan Forms
- Michigan Authorization for Release of Documents
- Michigan Authorization for Medical Employment Records
- Ascension Authorization for Release of Health Information
- Beaumont Authorization for Release of Health Information
- Detroit Medical Center Authorization for Release of Health Information
- Henry Ford Health System Authorization for Release of Health Information
- Michigan Department of Treasury Form 4095
- Oakwood Authorization for Release of Health Information
