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Medical Record Release
When a patient's records or information must be provided to another person or doctor it is necessary that they provide their consent by completing all information on this form. If the patient is under the age of 18 then you must make sure that a parent completes the consent to release medical records. All authorization forms must be placed in the patient file so the information may be referenced by the Doctor when the records or information is released to the authorized person.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Medical Record Release TemplateForm 4087
Format: Word PDF
Category: Medical, Hospital
Type: Release
Medical Record Release


From: Full Name
Mailing Address
City, State, Zip Code
Phone Number
Fax Number
Email

To : Full Name
Mailing Address
City, State, Zip Code
Phone Number
Fax Number
Email

RELEASE OF MEDICAL RECORDS & INFORMATION


I authorize

(Doctor/Hospital)

(Address, City, State, Zip Code)

To release

(Please be specific)

To

(Doctor/Person)

(Address, City, State, Zip Code)

For the purpose of

(Please be specific)

This consent is valid until

(Date: Month, Day, Year)

I authorize the release of medical records and information as described above. I understand this release of medical records and information may be discontinued at any time that I choose to do so in writing. I understand, if I make a request, that I can review and will be provided copies of the medical records and information released. I understand that if I discontinue my authorization for this release of medical records that it shall not effect records and information provided previously.

X __________________________________
Patient Signature and Date

X __________________________________

Parent or Guardian Signature and Date

X __________________________________

Witness Signature and Date