Medical Records Release Form


Hospital Name ____________________________________

Patient Name ____________________________________________

Patient Address____________________________________________

Patient Social Security No: ________________________

Patient Birth Date: ______________________________

I, the undersigned, authorize ____________________________ (Name of Hospital) to furnish medical information concerning the above-named patient to the following persons and institutions: _________________________________________________ ______________________________________________________________________ (Names and Mailing Addresses of Persons or Institutions Requesting Information). This medical information is to be limited to the following: ______________________ ______________________________________________________________________ (Specify Such Information as Medical Condition or Injury; Treatment, Examination, or Hospitalization Received; and Dates of Treatment).

The above-named persons and institutions may use the information authorized only for the following purposes: __________________________________________________
______________________________________________________________ (Specify). The further use or disclosure of the authorized information by the above-named persons and institutions may not be accomplished without my further written consent. This authorization shall become effective immediately and shall be valid until ______________________________ (Date), unless expressly revoked by me.

Patient Signature or Signature of Authorized Person

Relationship to Patient