Authorization for Release of Medical Records

How To Use

Remember to include the cover letter and read the review list prior to doing so.

This review list is provided to inform you about the Authorization for Release of Medical Records document in question and assist you in its preparation.

  • The Authorization must be signed and dated in two places by the patient or the patient’s authorized representative, such as a parent for a minor. The first signature specifies what medical records can and cannot be released. The second signature relates to the entire form.
  • Send two signed copies to the health care provider. They can keep one set and send you back the other.
  • If this release is for litigation purposes, your litigation lawyer should handle the matter directly with the Health Care Provider on your behalf.