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Back to Forms for 'Medical Consents & Releases'.





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

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