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)
