Download Medical Records Release Form

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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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