SAMPLE FORM:COPY, PASTE and EDIT.
AUTHORIZATION FOR EXAMINATION
I authorize you to furnish a copy of the
medical records of ________________________,
( name of patient of “myself” )
covering the period from _________,
20 ____ to ___________, 20 ____ or to allow those records to be inspected or copied by _____________________. I release you
from all legal responsibility that may arise from this authorization.