Medical Information Release Authorization Forms


Medical Information Release Authorization

To: (Medical Doctor or Hospital)

Ronald J. Webber
44 Predicament Place
Estrangement, NJ 08837
S.S.#: 123-45-6789

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