Medical Information Release Authorization
To: (Medical Doctor or Hospital)
Ronald J. Webber
44 Predicament Place
Estrangement, NJ 08837
This will authorize you to release to the firm of Romanowski Law Offices, or its designated representative, and bearers of this authorization, full and complete copies of all of my medical records, doctors’ reports, hospital reports, including X-rays, nurses notes, doctors’ order sheets, discharge summaries and any other information or items or record which they may request.
|Medical Information Release Authorization.pdf|