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RELEASE OF RECORDS

RELEASE OF RECORDS

FOR ATTORNEY TO INSPECT AND COPY

 

To: _______________________________ (administrator)

of ______________________________ (name of hospital)

 

Patient’s Name and Address: ________________________________

 

Social Security Number: _____________________

 

Birth Date: ___________________________

 

 

This is authority for you to permit _____________________ (name), my attorney, to copy, inspect, and examine any and all records, charts, reports, X-rays, and X-ray reports that may be at your hospital pertaining to my _________________ (injuries or illness) for which I was admitted on ____________________ (month & day), ________ (year), and confined until _______________________ (month & day), _________ (year).

 

 

________________________________                 ____________________

(Signature)                                                                                        (Date)



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