Free Medical Release Form Template
Medical Release Form
Please fill out this form to authorize the release of your medical records.
Patient Information
Name
Date of Birth
Phone number
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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