Free Medical Release Form 02
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MEDICAL RELEASE FORM

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:
[ATTORNEY'S 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 ABO