Your Name
Your Address
Date (MM/DD/YYY)Name of Hospital or DoctorAddressTo Whom It May ConcernI, (Your Name), hereby authorize (Hospital Name)
to release to (Name of Person or Doctor with his qualification), any
information in my personal medical records, including all x-rays, CAT scans,
and any other information pertinent to my treatment while I am under the care
of (Hospital Name) during the period from (Date of admission till date of
discharge). I give my permission for this medical information to be used for
the following purpose: to assist in the diagnosis and treatment of my
reoccurring abdominal pain. I do not, however, give permission for any other
use or for any re-disclosure of this information.Full name of PatientSignature of Patient Date of Signature
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