I hereby authorize the following health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription. What is a medical record release form? The sample medical release form is available online that can be used to create one in word doc format. I hereby authorize the release of my medical information to the designated recipient. To request release of medical information please complete and sign this form i, ____________________________________hereby voluntarily authorize the disclosure of.
