Medical Records Release Form
Also available in PDF | MS Word
One of the first steps in the process of assessing your legal claim is to review your medical records. Some personal injury lawyers have medical professionals on their staffs who assist in the records review process and then advise the attorneys on the medical aspects of the case. Other attorneys may seek the assistance of independent physicians outside of their office who are familiar with the types of injuries involved and who may even be called upon to testify if the case goes to trial. In any event, your attorney will need you to sign a release form like the one below so that your medical providers are authorized to provide a copy of your records to your lawyer.
Patient's name _____________________________________________
Date of birth ____/____/____
Social Security Number ______-___-_______
Telephone number (____) ____-_______
Please release my medical records from:
Name of provider __________________________________________
Please release all records, including but not limited to, progress notes, operative notes, laboratory test results, diagnostic tests, and x-rays.
I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE.
_______________________________________ Date: ______________________________