Can this release be signed electronically?

Yes. Electronic signatures are lawful under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; however, confirm any exception such as certain court-ordered records or documents excluded from e-signature acceptance.

Is a BAA required for vendors?

If a vendor handles protected health information, a HIPAA Business Associate Agreement is required before transmitting PHI; ensure the BAA is signed and stored with the release record.

Who may sign on behalf of the patient?

The patient, a legal guardian, healthcare proxy, or an agent under a valid power of attorney may sign; verify authority with attached documentation when not plainly evident.

How do I revoke a release once given?

A patient may revoke consent in writing; document the revocation, notify parties who received records, and rely on state law and record retention rules when determining whether already-disclosed information can be recalled.

What authentication level is recommended?

Use email plus SMS verification for moderate assurance and knowledge-based or two-factor authentication for high-assurance requests involving sensitive records or legal disclosure.

How should signed releases be stored?

Store signed releases with audit metadata in encrypted storage, maintain access controls, and retain copies per HIPAA (6 years) and applicable state retention requirements.

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Request for Additional Medical Information and Release

Request for Additional Medical Information and Release

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Request for Additional Medical Information

And Medical Release

(Pursuant to NRS 616C.177 & 616C.490(4))

Injured Employee's Name:

Claim Number:

Social Security Number:

Injured Employee's Address:

Injury/Occupational Disease Date:

Date this Notice Printed:

Insurer's Name:

Employer:

Insurer's Address:

Employer's Address:

Please provide the information requested below, sign and date the form, and return it to your insurer. Your signature on this form also acts as a release to acquire information affecting your claim from other entities. This renews the release you signed on your C-4 form at the time your claim was submitted to your insurer. Failure to fully complete and return this form to your claims agent in a timely manner could affect your benefits or delay the resolution of your claim.

Prior History Information

Please check the appropriate box below and provide the information requested.

I have no prior conditions, injuries or disabilities of which I am aware, that might affect the disposition of the claim referenced above. (If you checked this box, no further information is needed at this point)

I have a prior condition, injury or disability that could affect the disposition of the claim referenced above. This can include birth defects, prior surgeries, injuries, etc., whether work related or not. (If you checked this box, indicating a pre-existing condition, please explain in detail in the space below. Please attach additional sheets of paper to this form if necessary to fully explain the condition)

I certify that the above is true and correct to the best of my knowledge and that I have provided this information in order to obtain the benefits of Nevada's industrial insurance and occupational diseases acts (NRS 616A to 616D, inclusive or chapter 617 of NRS). I hereby authorize any physician, chiropractor, surgeon, practitioner, or other person, any hospital, including veterans administration or governmental hospital, any medical service organization, any insurance company, or other institution or organization to release to each other, any medical and other information, including benefits paid or payable, pertinent to this injury or disease, except information relative to diagnosis, treatment and/or counseling for aids, psychological conditions, alcohol or controlled substances, for which I must give specific authorization. A photostat of this authorization shall be as valid as the original.

Signature

Date

D-36 (Rev. 12/07)

What the Request for Additional Medical Information and Release Is

A Request for Additional Medical Information and Release is a written form used to ask a patient or third party to provide specific health records, clarifications, or authorizations and to grant permission to disclose protected health information to named recipients. The document typically identifies the requester, specifies the medical records sought, sets a time range and purpose, explains the scope of disclosure, and includes an explicit patient or authorized representative signature and date. For many uses it also documents consent for further release to insurers, employers, or legal counsel while noting any limits on redisclosure.

Why a Clear Request and Release Matters

Accurate, narrowly tailored requests reduce processing delays, protect patient privacy, and establish legal permission for covered entities to share records. A properly completed release supports claims processing, legal review, care coordination, and research while limiting unnecessary disclosure.

Who Typically Prepares and Signs This Request

Organizations or individuals who need access to medical records and lawful permission to receive them commonly prepare this form.

Parties completing or receiving the request should confirm authority to act and retain a signed copy for the record.

Step-by-Step: Completing the Request and Release

Follow a consistent order to ensure the release is lawful, complete, and immediately actionable.

01

Identify Parties: Enter requester and patient full legal names and contact details.
02

Specify Records: List dates and types of records requested (e.g., lab results, imaging).
03

State Purpose: Indicate the reason for disclosure (claims, legal, treatment) clearly.
04

Sign and Date: Patient or authorized rep signs; include printed name and relationship.

How the Request Flows Through an Organization

Typical routing steps show who reviews, approves, and transmits requested records.

Submission: Requester uploads or mails the completed release to medical records.
Verification: Records staff confirm signer identity and authority to release.
Redaction & Preparation: Staff redact unrelated sensitive entries and compile requested items.
Transmission: Records sent to designated recipient with audit note retained.

Digital Workflow Settings to Configure

When automating requests, set clear fields and authentication to match your compliance needs.

Field	Configuration
Signature Type	Electronic signature with audit trail
Authentication	Email + SMS code or KBA for high assurance
Data Redaction	Enable template redaction rules before sending
Retention Rule	Automatic archival per retention policy

Technical Requirements for Secure eSubmission

Ensure your platform supports required file formats, secure transmission, and audit logging before e-submitting a medical release.

Formats: PDF, DOCX accepted
Encryption: TLS 1.2/1.3 in transit
Audit Trail: IP, timestamp, signer events

Confirm the vendor supports HIPAA BAAs and long-term record export to meet regulatory and legal discovery needs.

Essential Elements to Include in a Professional Release

A complete Request for Additional Medical Information and Release contains six practical elements that protect patient rights and enable efficient handling.

Requester Identity

Full legal name, organizational affiliation, contact phone and email so the records office can validate the request and follow up if clarifications are needed.

Subject Patient

Patient full name, date of birth, and medical record number where known to reduce search time and avoid misidentification.

Records Description

Clear list of requested items (e.g., discharge summaries, imaging reports) and explicit date range to narrow the disclosure to what is necessary.

Recipient & Limits

Name and address of the recipient and any limits on redisclosure or purpose to preserve patient control over further sharing.

Duration & Expiration

Specify how long the release remains effective and the expiration date to prevent indefinite disclosures beyond the intended timeframe.

Signature & Authority

Signature of patient or authorized representative, printed name, relationship, and date; attach proof of authority if signing on behalf of the patient.

Security and Compliance Checklist for Handling Releases

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest

HIPAA BAA: Business Associate Agreement required

Audit Trail: Timestamped signer events retained

Access Controls: Role-based access and session timeouts

Certifications: SOC 2 Type II; ISO 27001 available

Long-Term Export: PDF/ZIP export with audit metadata

Consequences of Incomplete or Improper Releases

HIPAA Violations: Civil and criminal penalties for impermissible disclosures; documentation and mitigation required (45 CFR §164.502, §164.530).

Claims Delays: Incomplete records can delay insurance claims and appeals, causing denied or reduced benefits.

Legal Challenges: Ambiguous authority may lead to court disputes and motion practice over admissibility.

Breach Exposure: Excessive or misrouted disclosures increase breach risk requiring notification obligations.

Record Rejection: Records offices may reject requests lacking identity verification or required language.

Professional Liability: Providers may face malpractice or administrative scrutiny if records are shared without proper consent.

Typical Timing and Response Expectations

Specify a clear deadline in the request and allow adequate time for verification, redaction, and transmission.

Requester Deadline:

Commonly set a 14–30 day response window to allow identity verification and records retrieval.

Records Processing:

Medical records departments often require 5–15 business days depending on volume and search complexity.

Urgent Requests:

Mark as urgent for clinical care; expedited retrieval timelines may apply but incur fees.

Extension Notices:

Document any extension and reason to maintain auditability.

Retention of Copy:

Retain a signed copy for the requester and records office per retention policy.

eSignature Provider Comparison for Medical Releases

Comparison of starting price and key features relevant to secure medical releases and compliance; signNow is listed first per vendor order rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card required	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions and Solutions

Answers to common operational and compliance questions about requesting medical records and executing releases electronically.

Need help? Contact support

Can this release be signed electronically?
Yes. Electronic signatures are lawful under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states; however, confirm any exception such as certain court-ordered records or documents excluded from e-signature acceptance.
Is a BAA required for vendors?
If a vendor handles protected health information, a HIPAA Business Associate Agreement is required before transmitting PHI; ensure the BAA is signed and stored with the release record.
Who may sign on behalf of the patient?
The patient, a legal guardian, healthcare proxy, or an agent under a valid power of attorney may sign; verify authority with attached documentation when not plainly evident.
How do I revoke a release once given?
A patient may revoke consent in writing; document the revocation, notify parties who received records, and rely on state law and record retention rules when determining whether already-disclosed information can be recalled.
What authentication level is recommended?
Use email plus SMS verification for moderate assurance and knowledge-based or two-factor authentication for high-assurance requests involving sensitive records or legal disclosure.
How should signed releases be stored?
Store signed releases with audit metadata in encrypted storage, maintain access controls, and retain copies per HIPAA (6 years) and applicable state retention requirements.

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