(This form is used for a patient to authorize payment of the release of their records for particular purposes.)
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
TO WHOM IT MAY CONCERN
You are authorized to release to: [Name], any and all medical records related to treatment which I may had on the following approximate dates:
A photocopy of this authorization shall have the same force and effect as an original.
All prior authorizations are canceled.
Social Security Number: ______________
Date of birth: _______________