The Medical Records Release Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.
Medical Records Release Form Template UK Editable – PrintableSample
Medical Records Release Form Template UK 1. Patient Information 2. Health Care Provider Information 3. Purpose of Disclosure 4. Information to be Released 5. Expiration of Authorization 6. Right to Revoke 7. Acknowledgment of Understanding 8. Signature Authorization 9. Parent/Guardian Authorization (if applicable) 10. Contact Information for Further Questions
PDF
WORD
Examples
[Patient’s Full Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email]
[Requesting Party’s Name]
[Requesting Party’s Relationship to Patient]
[Requesting Party’s Contact Information]
This release form is intended to authorize the disclosure of medical records for the purpose of [Specify Purpose, e.g., legal review, personal record keeping, medical treatment].
I authorize the release of my medical records, including but not limited to
[List Off Specific Records, e.g., treatment records, diagnostic reports, immunization records].
This authorization will expire on [Expiration Date], unless revoked earlier in writing.
I understand that I have the right to revoke this authorization at any time by providing written notice to [Provider’s Name], provided that the revocation will not affect any disclosures made prior to the revocation.
I, [Patient’s Name], hereby authorize the release of my medical records as detailed above.
Signature: ________________________
Date: [Date]
Name: [Witness Name]
Signature: ________________________
Date: [Date]
[Full Name of Patient]
[Date of Birth]
[Home Address]
[Contact Number]
[Email Address]
[Recipient’s Name/Organization]
[Recipient’s Address]
[Recipient’s Phone Number]
This authorization allows for the transfer of medical information for purposes including [State Purpose, e.g., ongoing medical treatment, insurance verification, etc.].
I specifically authorize the release of the following medical information:
[Detail Specific Records, such as lab results, prescriptions, health history, etc.].
This authorization shall remain in effect until [Specify End Date or Event], unless revoked in writing by the undersigned.
I understand that I may revoke this authorization at any time, with the understanding that this will not affect actions already taken based on this authorization.
By signing below, I certify that I fully understand this authorization and its implications.
Signature: ________________________
Date: [Date]
Name of Authorized Individual: [Name]
Relationship to Patient: [Relationship]
Signature: ________________________
Date: [Date]
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