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Free Medical Release of information form - PDF Form Download

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Download and use this form for Authorization for the release of information.



medical-release-of-information-form

Text Version of this Form

Medical Release of Information Form

TO WHOM IT MAY CONCERN:

Please furnish to ___________________________________(hereinafter “Facility”) and/or any or all of its personnel, information, copies of any and all hospital and medical record or reports of any sort, charts, notes, x-rays, lab reports and prescription information, including the right to inspect and coy such records. Facility is to be furnished any and all other information without limitation pertaining to any confinement, examination, treatment or condition of myself, including medical, dental, psychological or other treatment, examinations, or counseling for any condition, medical, dental or psychological.

This AUTHORIZATION shall be considered as continuing and you may rely upon it in all respects unless you have previously been advised by men in writing to the contrary. It is expressly understood by the undersigned and you are hereby authorized to accept a copy of photocopy of this medical authorization with the same validity as though an original had been presented to you.

 

Dated this  _____________________day of ______________, 20 ____________.

 

Signature: ________________________________________________________

 

Name:      _________________________________________________________

Address:  _________________________________________________________

_________________________________________________________

Phone:    ________________________  Email: ___________________________

 

 

 

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