Free Medical Records Release Form Template
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.
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Complete Medical History
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Lab Test Results
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Imaging Reports
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Immunization Records
-
Mental Health Records
Purpose of Release
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Personal Use
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Continuing Medical Care
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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:
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