This Release of Medical Information is also available as a Word document (16 KB)
Permission to share my medical records
I, [patient’'s name], born on [patient’s date of birth], give my permission for my doctor/hospital [name of doctor or hospital that has the records] to give the medical records (described on page 2) to [doctor who needs the records] so that they can better understand my condition and help me.
Permission to share sensitive information
You have my permission to share my records about topics below ONLY IF my initials are next to it.
- My mental health.
- Any disease I may have that others could get from me, like HIV or hepatitis.
- My genes.
- My use of drugs or alcohol.
By signing below, I show that I understand:
- I do not have to share these records.
- The permission I am giving is good for only 3 months from the date I sign.
- If I want to stop sharing my medical records before then, I need to talk to the doctor’s office or hospital that has the records and find out what I need to do to stop the sharing.
Patient's or Authorized Representative’s Signature and Date.
Relationship of Authorized Representative:
Consent for release of medical records for [patient’s name]
The doctor who needs the records will fill out this page.
Requesting records from:
Name of Practice:
Name of Physician:
Fax number/secure email address:
Address:
Types of records we are requesting:
- Any and all types of records you have for this patient
- Doctor visit notes
- Doctors orders
- Emergency room notes
- Nurses notes
- Urgent care notes
- Discharge summary
- History and physical
- Lab reports
- Hospital progress notes
- Radiology reports
- Operation or procedure notes
- Consultations
- Clinic notes
- Other
- Pathology reports
Records within the following dates:
All dates
Records dated between [date] and [date]
Please send records to:
Attention:
At fax number:
or secure email:
Or mail to:
For any questions please call (phone number):
and ask for: