Inter-Facility Medical Information Release
Patient Information
Full Name
Date of Birth
Medical Record Number
Releasing Facility
Facility Name
Address
Phone
Receiving Facility
Facility Name
Address
Phone
Information to Be Released
Purpose of Release
Dates of Service to Release
Authorization and Signature
By signing below, I authorize the release of my medical information as described above.
Signature
Date
This authorization is valid for one year unless otherwise specified or revoked in writing. A photocopy is as valid as the original.