Medical Release Form

Medical Release Form

Please fill out this form to authorize the release of your medical records.

Patient Information

Name

    Date of Birth

      Phone number

        Email

          Recipient Information

          Recipient/Organization Name

            Information to Be Released

              Purpose of Release

                Release Authorization

                I hereby authorize the release of my medical information to the designated recipient. This authorization includes the release of my medical records for the specified purpose. I understand that this authorization will remain in effect until I revoke it in writing.

                Name:

                Date:

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