Medical Record Release Authorization

I. PATIENT INFORMATION

• Full Name: Efrain Abshire

• Age: 40

• Address: Shreveport, LA 71101

• Phone Number: 222 555 7777

• Email Address: efrain@you.mail

II. RECORDS TO BE RELEASED

Please check the appropriate box for the medical records you wish to release:

Type of Record	Check Box
Medical History
Treatment Records
Lab Results
Prescription Information
Immunization Records
Radiology Reports
Other (Specify): [N/A]

III. RELEASE TO

• Recipient Name: Dr. Alice Johnson

• Address: Shreveport, LA 71101

• Phone Number: 222 555 7777

• Fax Number: 222 555 7777

IV. PURPOSE OF DISCLOSURE

Please check the appropriate reason for the release of medical records:

Reason	Check Box
Personal Use
Insurance Purposes
Legal Purposes
Employment
Other (Specify): [N/A]

V. AUTHORIZATION

By signing below, I authorize the release of my medical records as specified above. I understand that I have the right to revoke this authorization at any time by notifying [YOUR COMPANY NAME] in writing. This authorization is valid until 12/31/2081 unless I specify otherwise.

Efrain Abshire
Date of Signature: 12/03/2081
Relationship to Patient (if applicable): N/A

VI. CONFIDENTIALITY NOTICE

The information provided under this authorization will be kept confidential as per the guidelines of HIPAA and other applicable laws. The information may not be disclosed to anyone other than the named recipient unless specifically authorized by law.

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