Medical Release Form

Information you will need

• What's the releasor's name
• What's the recipient's name?
• What's the contact's name?
• What's the recipient's address?
• What's the recipient's e mail?
• What's the recipient's phone number?
• What records should be released?
• Why is this authorization being made?
• What's the recipient's fax number?
• When will this authorization expire?
• Should sensitive information be included?
• What records are authorized for release?
• What’s the signer's printed name?
• What's the patient's name?
• What's the patient's date of birth?
• What's the patient's address?
• What's the patient's SSN?
• What's the personal representative's relationship to the patient?

Completed by the recipient.