MEDICAL RECORDS RELEASE
DATE: ______________________
TO:_________________________________________________
Doctor or Hospital
_________________________________________________
Address
I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE
TO:__________________________________________________
Doctor or Hospital
__________________________________________________
Address
THE COMPLETE MEDICAL RECORDS IN YOUR POSSESSION CONCERNING MY ILLNESS AND/OR TREATMENT DURING THE PERIOD FROM
____________________TO ________________________
SIGNED: _________________________________
Patient or Nearest Relative
RELATIONSHIP: ________________________________
WITNESS: __________________________________
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