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Form #1046Authorization for Release of Records
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Authorization For Release of Information - Free Legal Form
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Submissions to this site, including any legal or business forms, posts, responses
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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.
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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.
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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
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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
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acceptable in one state may not be enforced the same way under the laws of another
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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
Our Spam Policy
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regading how we deal with your email. We pledge that we will:
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party without your explicit consent
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, authorization for release, release
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