PATIENT WAIVER 
 
 
I, _____________________________________ (patient, or guardian, or trustee, or
conservator, etc.), do hereby authorize the release of any and all medical documents
of whatever nature and form of any and all health care providers, including:
________________________________________________________________________________
________________________________________________________________________________ 
(name(s) of care provider(s) for the aforementioned individual).  The social security
number of the patient is ____________________________, and the date of birth of the
patient is __________________. Please disclose to ______________________________
________________________________________________________________________________
________________________________________________________________________________ 
(name(s) of individual(s) to whom medical records are to be disclosed) all medical
records of every nature and form pursuant to this request, with the following
exceptions: ____________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
(list of medical records that are not to be disclosed).  It is understood that any
documents disclosed may be used for any and all purposes.  This request hereby
includes any information that may be protected by any federal or state laws, unless
specifically noted in the foregoing. 
 
Dated this _____ day of ____________________, 20___, at _____________________________. 							        (city, state)

						_______________________________________ 
						(Signature) 

						_________________________________________ 
                                         	(Witness) 





LAWCHEK, LTD. LETTER PRO Samples, Copyright 2006 
This is not a substitute for legal advice.  An attorney must be consulted.