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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 ______-___-_______

Address ______________________________________________
______________________________________________
______________________________________________
______________________________________________

Telephone number (____) ____-_______

Please release my medical records from:

Name of provider __________________________________________
Provider's address __________________________________________
__________________________________________
__________________________________________
__________________________________________

TO:

[ATTORNEY'S NAME AND ADDRESS HERE]

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: ______________________________
Patient's Signature

Next Steps
Contact a qualified medical malpractice attorney to make sure
your rights are protected.
(e.g., Chicago, IL or 60611)

Help Me Find a Do-It-Yourself Solution