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
Phone number
Fax number
| Print Name of Patient: | ______________________________________ |
| Patient's Complete Current Address: | ______________________________________ |
| Signature of Patient: | ______________________________________ |
| Patient Date of Birth: | ______________________________________ |
| Date: | ______________________________________ |
