Free Medical Release Form 17Free Medical Release Form 17
Download the document to the computer for easy use
There are more pages to preview,Read on

AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize the named health care provider to release the information or records specified to upon
request in person or by mail to the address specified at the time of the request.
Provider: ___________________________________________
(name and address)
Patient: _____________________________________________
SS#: ________________________________________________
DOB: _______________________________________________
RECORDS AUTHORIZED TO BE RELEASED:
Admission history and physical

Discharge summary

Complete hospital chart

Office notes

Outpatient records

Lab reports

Radiological images

Consultation notes or reports

Complaints or grievances filed, with responses or dispositions
Psychiatric and other mental health records
Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be
released) Medication administration logs, dietary logs, staff contact or service logs, and other records
that may not be pa