Sample Medical Records Release Authorization

TO: _____________________________________

ADDRESS: _________________________________

I hereby authorize you to release my medical records, including operative reports, radiology reports and film copies, pathology reports and slides, and discharge summaries to:

Your name, address, & affiliation
Phone number
Fax number

Print Name of Patient:	______________________________________

Patient's Complete Current Address:	______________________________________

Signature of Patient:	______________________________________

Patient Date of Birth:	______________________________________

Date:	______________________________________