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Form #1050Release 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
)
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regading how we deal with your email. We pledge that we will:
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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.
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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
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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