Section 18 Medical Authorization Form

• Library: Civil Trial Practice 2008 Supp Forms

Authorization to Disclose Medical Information

Patient Name: _________________________________________________________________
Patient ID Number or Date of Birth: _______________________________________________

To: _________________________________
_________________________________

1._ I authorize the use or disclosure of the above-named individual's health information as described below.

2._ The type and amount of information to be used or disclosed is as follows:

___________________________________________________________________________

___________________________________________________________________________

3._ I understand that the information in the health and medical records may...