Medical Release Form Template

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Customize a Medical Release Form to authorize a healthcare professional to see your confidential medical records. The private nature of medical records requires you to properly authorize the release of medical records from one healthcare professional to another. Fill in the blanks provided and you will have a customized Medical Release Form tailored to your specific healthcare needs. This Medical Release Form can be used by individuals to authenticate the release of their medical records from one health care professional to another.

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									Customize this Medical Release Form to authorize a healthcare professional to see your
confidential medical records. The private nature of medical records requires you to
properly authorize the release of medical records from one healthcare professional to
another. Fill in the blanks provided and you will have a customized Medical Release
Form tailored to your specific healthcare needs. This Medical Release Form can be
used by individuals to authenticate the release of their medical records from one health
care professional to another.
                          MEDICAL RELEASE FORM TEMPLATE

I, _____________________, born on _____________________, Social Security Number
______________,   hereby    authorize    _____________________    to     release    to
_____________________, the medical information from my personal medical records listed
below.

Medical Records Released

I authorize _____________________ to release to _____________________ the following
medical records:

______________________________________________________________________________
______________________________________________________________________________

Purpose of Release

I give my permission for this medical information to be used for the following purpose:

______________________________________________________________________________
______________________________________________________________________________

I do not give permission for any other use or re-disclosure of this information.

Expiration Date

This Medical Release will expire on _____________________.

Future Medical Records

I give permission for the following medical records that will be created in the future to be
released to _____________________:

______________________________________________________________________________
______________________________________________________________________________

Medical Records Not Authorized

I do not intend to release the following personal medical records and I strictly forbid
_____________________ from releasing the following medical information:

______________________________________________________________________________
______________________________________________________________________________


________________________________


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