Medical Records Release Form
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The blank medical release form gives a patient the right to hand over his or her private records to someone else by the authorization of this document.
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The patient may grant all or part of his or her documents including:
- Admission history and physical
- Discharge summary
- Office Notes
- Outpatient records
- Psychiatric and other mental health records
- Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be released).
- Medication administration logs, dietary logs, staff contact or service logs, and other records that may not be part of my individual medical record, but which contain information relating to me.
- Lab reports.
- Radiological images
- Consultation notes or reports.
- Complaints or grievances filed with responses or dispositions.
Download (PDF, 96KB)
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