The Medical Release Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. Each version is designed to be both editable and printable to accommodate your specific requirements easily.
Medical Release Form Template – Canada Editable – PrintableSample
1. Patient Information 2. Authorized Recipient(s) 3. Purpose of Disclosure 4. Specific Information to be Released 5. Duration of Authorization 6. Right to Revoke 7. Acknowledgment of Understanding 8. Signature and Date 9. Witness Information 10. Contact for Questions
PDF
WORD
Examples
[Patient’s Full Name]
[Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email Address]
[Healthcare Provider’s Name]
[Provider’s Address]
[Provider’s Phone Number]
[Provider’s Email Address]
This Medical Release Form authorizes the disclosure of the patient’s medical information for the following purpose(s):
[Specify Purpose, e.g., continuing care, insurance claims, etc.]
The specific medical information to be released includes:
[Specify the types of information, e.g., medical history, treatments, laboratory results, etc.]
I hereby authorize the above-mentioned healthcare provider to release my medical information as described above to [Recipient’s Name & Relationship].
This authorization will remain in effect until [Specify Expiration Date] unless revoked in writing by the patient.
_____________________________________
[Patient’s Name]
[Date]
Name of Personal Representative: [Representative’s Name]
Relationship to Patient: [Relationship]
Signature: _____________________________________
Date: [Date]
[Patient’s Full Name]
[Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email Address]
[Health Facility’s Name]
[Facility’s Address]
[Facility’s Phone Number]
[Facility’s Email Address]
This form is intended to provide the necessary authorization for the release of medical records for:[Specify Purpose, e.g., legal reasons, employment purposes, etc.]
The following information is to be released:
[Specify the information to be disclosed, e.g., psychological evaluations, treatment summaries, etc.]
I, the undersigned, authorize the aforementioned health facility to disclose my medical information as listed above to [Recipient Details].
This consent shall remain valid until [Specify End Date] or unless revoked by the signer in writing.
_____________________________________
[Patient’s Name]
[Date]
In case the patient cannot sign, please provide the name of the authorized representative: [Representative’s Name]
Relationship: [Relationship]
Signature: ___________________________________
Date: [Date]
Printable
