I hereby authorize the following health care professional, medical facility, mental health facility, laboratory, paramedical facility, medical examiner, medical records service, prescription. The sample medical release form is available online that can be used to create one in word doc format. Completed and signed forms can be submitted the following ways: To request release of medical information please complete and sign this form i, ____________________________________hereby voluntarily authorize the disclosure of. Fax or mail the appropriate site listed on page 2 of the.
