Medical Records Release Form
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1Medical Records Release Form
Client Name: ___________________________________________________________________
Address: ______________________________________________________________________
City: ______________________________________
State: __________
Province: _______
Country: __________________________________
Zip/Postal Code: ___________________
Telephone: __________________
Fax: _________________
Email: __________________
Date of Birth: ______________________________
Social Security Number: _____________
I authorize the release of my medical records or other health care information, including intake
forms, chart notes, reports, correspondence, billing statements, and other written information
concerning my health and treatment during the period of __________ to __________ ; to be sent
to the following person or company.
Company: _____________________________________________________________________
Address: ______________________________________________________________________
City: ______________________________________
State: __________
Province: _______
Country: __________________________________
Zip/Postal Code: ___________________
Telephone: __________________
Fax: _________________
Email: __________________
Client Signature: _______________________________
Date: ________________________
This authorization is valid until: ___________ .
date
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Parent category: Legal