Hospital Patient Release Form

Hospital Patient Release Form
Patient Name
First NameLast Name
Date of Birth
MonthDayYear
1
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I am the patient or the legally authorized representative of the patient specified above. I request that the health information be released to:
(Please fill out the applicable parts below.)
Name of Person/Physician
First NameLast Name
Organization Name
Hospital, etc.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Information Delivered Via
Picked up by
Fax
Purpose of disclosure/release
Other
Requested Information
Other
Please give details about the requested information
I, undersigned , agree with the following statements:
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Medical Record Department of the entity authorized to release this information. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company as the law provides my insurer with the right to contest a claim under my policy.
The person who requesting release of information is
Other
Name of Undersigned
First NameLast Name
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: