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Form #1046

Authorization for Release of Records

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Authorization For Release of Information - Free Legal Form

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AUTHORIZATION FOR RELEASE OF RECORDS

 

 

Authorization For Release of Information

 

____________________________________ (Name of Hospital)

 

 

Patient Name and Address: ____________________________________________

 

Social Security No: ________________________

 

Birth Date: ______________________________

 

 

I, the undersigned, authorize ____________________________ (Name of Hospital)

to furnish medical information concerning the above-named patient to the following persons and institutions: _________________________________________________

______________________________________________________________________ (Names and Mailing Addresses of Persons or Institutions Requesting Information).

 

This medical information is to be limited to the following: ______________________ ______________________________________________________________________ (Specify Such Information as Medical Condition or Injury; Treatment, Examination, or Hospitalization Received; and Dates of Treatment).

 

The above-named persons and institutions may use the information authorized only for the following purposes: __________________________________________________

______________________________________________________________ (Specify).

 

The further use or disclosure of the authorized information by the above-named persons and institutions may not be accomplished without my further written consent.

This authorization shall become effective immediately and shall be valid until ______________________________ (Date), unless expressly revoked by me.

 

 

 

______________________________________                                                ______________

Signature of patient or Authorized Person                                                 Date

 

__________________________________

Relationship to Patient

 

 

______________________________________                                                ______________

Witness                                                                                                                             Date

Contributed by
Anonymous4
 
Name of Firm Anonymous4
Total Forms Contributed 75
 

See All Anonymous4's Forms
 

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Terms Of Use

Submissions to this site, including any legal or business forms, posts, responses to questions or other communications by contributors are not intended as and should not be construed as legal advice. You are strongly encouraged to consult competent legal council before engaging in any action based upon content contained on this site.

These downloadable forms are only for personal use. Retransmission, redistribution, or any other commercial use is prohibited. This includes reposting forms from this site to another site offering free legal or other document forms for download.

Please note that the donator may have included different usage terms regarding this form, and you agree to abide by these terms. It is highly recommended that you have a licensed attorney review any legal documents for which you are searching in order to make sure that your needs are being properly and completely satisfied.

Your use of this site constitutes your acceptance of our terms of use and your agreement to hold this site, its officers, employees and any contributors to this site harmless for any damage you might incur from your use of any submissions contained on this site. If you do not agree to the above terms, please do not proceed.

These forms are provided to assist business owners and others in understanding important points to consider in different transactions. They are offered with the understanding that no legal advice, accounting, or other professional service is being offered by these documents or on this website. Laws vary in the different states. Agreements acceptable in one state may not be enforced the same way under the laws of another state. Also, agreements should relate specifically to the particular facts of each situation. Therefore, it is important to consult legal counsel whenever utilizing these forms. The Forms are not a substitute for legal advice YourFreeLegalForms.com is not engaged in recommending or referring members on the site or making claims about the competence, character or qualifications of its participating members.
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Comments

submitted 9/26/2008
by MitchDenver 

"I run a small business and a guy I rely on has been taking time off. Claims he has hospital appointments. His work has been suffering. This form should tell me whether I’m looking for a new key employee or my guy will recover and keep the business running smoothly. Really useful to find a form like this for free. Hope you make the site pay and build up a good inventory of forms. There are a lot of contracts that would help us grow. Free is always best so long as the quality’s there."
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