Medical Record Liability Release
Prepared by: [YOUR NAME]
Introduction
This Medical Record Liability Release ("Release") is made for the purpose of facilitating medical referrals or transfers of care. By signing this Release, the undersigned patient or their legal representative authorizes [YOUR COMPANY NAME] to release the patient’s medical records to the designated healthcare provider or institution for the purposes of continuing medical care. The undersigned also releases [YOUR COMPANY NAME] from any and all liability that may arise as a result of the release of these medical records, provided such release is done in accordance with the patient’s consent.
Medical Record Liability Release
Patient Information:
Full Name: Derek Hudson
Date of Birth: June 12, 2005
Address: 4748 Nixon Avenue, Staten Island, NY 10301
Phone Number: (718) 321-6701
Email: derek@email.com
Releasing Party (Provider/Company):
Company Name: [YOUR COMPANY NAME]
Contact Person: Rachel Whitmore
Company Address: [YOUR COMPANY ADDRESS]
Phone Number: [YOUR COMPANY NUMBER]
Email: rachel@email.com
Website: [YOUR COMPANY WEBSITE]
Social Media: [YOUR COMPANY SOCIAL MEDIA]
Receiving Party (Healthcare Provider/Institution):
Full Name: Dr. Jasmine Steele
Address: North Shore Medical Group, 1824 Conover Road, Brooklyn, NY 11214
Phone Number: (718) 927-8812
Email: jasmine@email.com
Details of Records to Be Released:
The records that will be released include, but are not limited to:
Medical history and treatment notes
Lab and diagnostic test results
Imaging records (X-rays, MRIs, etc.)
Medications and prescriptions
Specialist consultation reports
Other (Specify): Surgical records from the past 5 years
Purpose of Release:
The purpose of this Release is to facilitate the referral or transfer of medical care to the Receiving Party for continued medical treatment.
Liability Waiver:
By signing below, I authorize [YOUR COMPANY NAME] to release my medical records to Dr. Jasmine Steele for the above-stated purpose. I acknowledge that this Release waives any legal claims against [YOUR COMPANY NAME] arising out of the release of my records, so long as the records are released in compliance with my instructions as outlined herein.
Duration of Authorization:
This authorization is valid until December 31, 2055, unless otherwise revoked in writing before that date.
Patient's Signature
Printed Name: Derek Hudson
Date: August 15, 2050
Representative's Signature (if applicable)
Printed Name: Amanda Hudson
Relationship to Patient: Mother
Date: August 15, 2050
Witness Signature
Printed Name: Brian Roberts
Date: August 15, 2050
Provider's Signature
Printed Name: Rachel Whitmore
Title: CEO
Date: August 15, 2050
This Release of Liability ensures that the patient's medical records are shared safely and legally, allowing for the seamless continuation of care with the new healthcare provider.
Release of Liability Templates @ Template.net
