MEDICAL RELEASE FORM - DOC 3 by HC121003165552

VIEWS: 36 PAGES: 1

									AUTHORIZATION TO RELEASE MEDICAL INFORMATION




Patient’s Name:___________________________

Date of Birth:____________________________

Social Security #:_________________________



I request and authorize to release healthcare information of the patient named above to:



U-MED CENTER
67892 M-152
Dowagiac, Michigan 49047


This request and authorization applies to:



  o Healthcare information relating to the following treatment, condition, or dates:



  o All healthcare information



   o Other:



Patient Signature:__________________________

Date Signed:____________________




THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

								
To top