AUTHORIZATION AND WAIVER FOR RELEASE OF
TO: [NAME OF DOCTOR]
I authorize and instruct you to release to me full and complete copies
of all records, reports, and information concerning me, including, but
not limited to medical records, hospital records and reports, treatment
records, clinical notes, radiology reports, laboratory reports, bills,
accountings, incident reports, occurrence reports, and all
This Authorization and Waiver applies to any diagnosis, evaluation,
hospitalization, confinement, care or treatment I may have received at
any time and for any condition.
Please call me at [phone number] when the records are ready for pick up.
Please mail the records to me at the address stated below.
[YOUR NAME] DATE