AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
I hereby request and authorize the release of all information, without limitations regarding
any physical and mental condition, as revealed by your observation or treatment, past, present
This includes medical, surgical and dental history, x-ray findings, diagnosis, prognosis and
access to all hospital records and photocopies of the same.
I request that you release the above information to:
Please sign your name either using your fingers for touch devices or using your mouse.