Records Release form {example}


Patient’s name _____________________________________________

Date of birth ____/____/____
Social Security Number ______-___-_______
Address
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Telephone number (____) ____-_______

Please release my medical records from:
Name of provider
__________________________________________
Provider’s address
__________________________________________
__________________________________________
__________________________________________
__________________________________________


TO:
[NAME AND ADDRESS HERE]




Please release all records, including but not limited to, progress notes, operative notes, laboratory
test results, diagnostic tests, and x-rays.

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE.

Date: ______________________________

Patient’s Signature:________________________________________