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Back to Forms for 'Medical Consents & Releases'.


AUTHORIZATION FOR RELEASE OF RECORDS

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



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