Medical Records Release Form

You need to conduct an initial review of your medical records before you can actually file a legal claim. 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. In some cases, the lawyers will not be competent enough to evaluate the scenario. In times like this, he will need the assistance of a physician in handling the case. 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


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