Child Medical Consent
Child Travel Consent
Cohabitation Agreement
Common Law Partner Agreement
Health Care Directive
Last Will and Testament
Living Will
Medical Consent
Medical Records Release
Prenuptial Agreement
Separation Agreement


Bill of Sale
Business Plan
Cease & Desist Letter
Confidentiality Agreement
Employment Contract
Letter of Intent
Loan Agreement
Non-Disclosure Agreement
Partnership Agreement

Real Estate

Commercial Lease Agreement
Contract for Deed
Eviction Notice
Land Contract
Notice of Lease Violation
Notice of Rent Increase
Notice to Quit
Notice to Repair
Quitclaim Deed
Residential Lease Agreement
Get unlimited access to all documents!   180-day subscription   360-day subscription
Personal Documents and Forms - Medical Records Release
This item costs:

By clicking on “Purchase” you agree to the Terms of Service and our Privacy Policy. If you are unsatisfied with your purchase you may request a full refund, no questions asked. View our complete Refund Policy here.

If you do not have an account, one will be created upon completing your purchase and your account details will be delivered to you. Please treat your account details as personal and confidential information.
You are viewing “Medical Records Release”. To purchase this product and add it to your documents and filings, proceed to the payment page by clicking Purchase. If you do not have an account, one will be created during your purchase. If you have an account, please sign in using the “My Account”-link before proceeding with your purchase.

Additional notes, information and preview:


THIS MEDICAL RECORDS RELEASE (the "Release") is made $month $day, $year.


______________________________, ______________________________, ______________________________, ______________________________, ______________________________, ______________________________,
Phone: ______________________________, Fax: ______________________________ and all employees, contractors, and associated individuals thereof;

TAKE NOTICE THAT I,  ________________________________________ (the "Patient"), do hereby request the following information be released:

Medical Records

1. All medical and health information contained within:

  1. Charts;
  2. Notes;
  3. Reports;
  4. Records;
  5. Medication lists, and other lists;
  6. Prescriptions;;
  7. Flowcharts;
  8. Emails;
  9. Memorandum;
  10. Orders;
  11. Lab results;
  12. Test results, and analysis;
  13. Information related to treatment for any sexually transmitted disease, including HIV or AIDS;
  14. Information related to treatment for mental health illnesses;
  15. Information related to treatment for substance abuse;
  16. Diagnostic images and reports, including but not limited to X-Rays and EKG tracings;
  17. Photographic images; and
  18. Digital recordings, including but not limited to digital images.

1.2  All information related to the accounting of the Patient’s files, including but without limitation to Statements of Account.

1.3 All other authorizations previously received for the release of any or all of the Patient’s medical information.

1.4 All of the above is collectively referred to as “Medical Records”, as represented on paper, kept in folders, digitally, electronically, or any other form.

1.5 "Medical Records" also includes production of any documents or material by physicians, nurses, chiropractors, dentists, therapists, counselors, consultants, technicians, and any and all staff of the organization to which this Release is directed.


2.  I ask that the Patient’s Medical Records be released to me, for my own personal use.


3. I ask that the Patient's Medical Records be released within the next 30 days as required by the Health Insurance Portability and Accountability Act.

Notice and Additional Information

4. The contact information and particulars of the Patient are as follows:



Date of Birth:

$month $day, $year

Street Address:










Home Phone Number:


Cell Phone Number:




Duration of Medical Records Release

5. This Release will be valid until such time that you receive written notice from me revoking this Release, or until $month $day, $year.

Continuance of Ongoing or Future Care

6. This Release does not affect any ongoing or future care of the Patient.

SIGNED at ________________________________________, in the presence of:



Document and Filing Support

Once your purchase is complete you may start to personalize your document or filing. You can also request assistance from one of our service professionals regarding this document or filing.