More examples in Forms/Medical & Injury Forms
Authorization to Release Personal Injury Records Example
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Text in this example:
You are hereby Authorized and requested to furnish to or his representative, all my medical and drug records (including x-rays, if any), and reports, abstracts, and summaries thereof, accident and/or police reports, employment and earnings, histories and records, bills and statements, and all other information pertaining to me, to permit them to examine all originals and to make copies thereof. DATE NAME ADDRESS Authorization to Release Records