Medical Information Release Authorization

I, name* hereby authorize facility which has information* to release any and all pertinent health and medical information including diagnoses, tests, lab
reports, prescriptions, procedures, and notes to   business name or person*   . This release of information will remain in effect until terminated by me in writing.

Signature*   



 • I have the right to receive a copy of this authorization
• I authorize the disclosure of my identifiable health information as described above.
• I have the right to terminate this authorization and revoke permission to release
information. The revocation must be made in writing and will not affect information
that has already been disclosed.
• I understand that the person to whom my medical information is disclosed pursuant to
this agreement may not further use or disclose the information unless another
authorization is obtained from me or unless such disclosure is required by law.
• I am signing this authorization voluntarily.