Hospital Discharge Records Release Form

Hospital Discharge Records Release Form
Please complete this form to authorize the release of your hospital discharge records.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hospital Name
Date of Admission
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Discharge
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Recipient Name (Person or Organization to receive records)
Recipient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for Release
Patient or Authorized Representative Signature
Clear
Date of Signature
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: