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Form #1050

Release of Medical and Psychiatric Records

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Authorization For Release Of Medical Records - Free Legal Form

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RELEASE OF MEDICAL AND PSYCHIATRIC RECORDS

 

 

Authorization For Release Of Medical Records

 

__________________________________ (name of hospital)

 

Patient’s Name and Address: _________________________________________

 

Social Security Number: __________________________

 

Birth Date: __________________

 

 

I authorize you to release to the persons listed below information concerning the medical and psychiatric evaluation and treatment received by the above named patient at ________________________ (name of hospital) during the approximate period from ____________________ (month & day), _________ (year), to __________________ (month & day), __________ (year).  This information is to be used only for the purposes of ___________________________________________________________

(assisting in the pursuit of a legal action and obtaining psychotherapeutic and medical care).

 

The authorized information is to be provided only to the following persons: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

(names and addresses of persons to receive information).

 

This authorization is valid for __________ (number) days.  I understand that I may revoke this consent at any time by sending a written notice to the _________________

 

 

______________________________________________________________________

(Director of Medical Records or the person authorized to release information or to supervise its release).

 

 

I understand that I may review the disclosed information by contacting the ______________ ___________________________ (Director of Medical Records or the person authorized to release information or to supervise its release).

 

 

__________________________________

(Signature of Patient or Person Authorized to Consent For Patient)

 

___________________________                                             ____________________

(Relationship to Patient)                                                                 (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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Keywords: legal forms, release, medical, psychiatric records

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