Medical Information Release Form Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Release of Information* I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:* Spouse Child(ren) Other Spouse First Middle Last Child(ren) First Middle Last Other First Middle Last The best time to reach me:* : Hour Minute AM PM The best day to reach me:*MondayTuesdayWednesdayThursdayFridaySaturdaySundaySignature*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.