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