Medical Records Release Form

(This form is used for a patient to authorize payment of the release of their records for particular purposes.)

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

TO WHOM IT MAY CONCERN

You are authorized to release to: [Name], any and all medical records related to treatment which I may had on the following approximate dates:

A photocopy of this authorization shall have the same force and effect as an original.

All prior authorizations are canceled.

___________________________

Patient

Social Security Number: ______________

Date of birth: _______________