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Medical Records Release Form

(This form is used for a patient to authorize payment of the release of their records for particular purposes.)

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.

______________________

Patient

Social Security Number:

Date of birth:

*** If Required By State Law ***

This Section for Notary:

Acknowledgment

STATE OF -------)

) ss: [date]

COUNTY OF ------)

On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

[signature]

[Name of Notary Public]

My commission expires: [date]

(Seal)