AUTHORIZATION FOR RELEASE OF RECORDS
Authorization For Release
of Information
____________________________________ (Name of
Hospital)
Patient Name and Address:
____________________________________________
Social Security No: ________________________
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.
______________________________________ ______________
Signature of patient or Authorized Person Date
__________________________________
Relationship to Patient
______________________________________ ______________
Witness Date
