Medical Records Release Form Template
Share
Medical Records Release Form
Please complete this form to authorize the release of medical records.
Name
Date of Birth
Email Address
Records to be Released
Check all that apply.
Complete Medical History
Lab Test Results
Imaging Reports
Immunization Records
Mental Health Records
Purpose of Release
Personal Use
Continuing Medical Care
Insurance Claims
Legal Purposes
Consent and Agreement
I understand that this authorization allows the release of confidential medical information. I acknowledge that I have the right to revoke this authorization at any time by submitting a written request, except where action has already been taken. This authorization expires on upon completion of the requested release.
Name:
Date:
Thank You for Submitting!
We will give you an update soon.
Create free forms at Template.net
Templates
Form
Templates
