A General Medical Release forms are used to give general medical information that may be required for certain reasons such as by the state or federal government. The General Medical Release form gives authority to the mentioned persons to use their medical report for the required purpose and as per the agreement. A Sample General Medical Release form is below.
Sample General Medical Release Form
Authorization for Use or Disclosure of Imaging Information:
This authorization for use or disclosure of my health information is required by state or federal law.
Patients Name________________________________________________________
Date of Birth_________________________________________________________
Telephone Number___________________________________________________
Social Security number_________________________________________________
I hereby authorize the use or disclosure of my health Information:
Name of person/organization releasing information ___________________________________________________________________
Street Address_______________________________________________________
City_____________________ State ___________________ Zip Code__________
To release my health information to:
Name of person/organization releasing information to ___________________________________________________________________
Street Address_______________________________________________________
City_____________________ State ___________________ Zip Code__________
This authorization applies to the following:
All Records _______ Lab _______ Imaging Reports _______ Immunization _______
Other ______________________________________________________________
The recipient may use my health information only for the following specific purpose(s):
___________________________________________________________________
___________________________________________________________________
__________________________________________________________________
Patient Signature ________________ ____________Date ____________________
Patient Representative Signature _________________________________________
Relationship to Patient _________________________________________________
