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After a serious accident, a representative from the insurance company might ask you to sign a medical release form after you submit your claim. Signing the release means that you agree to supply the insurance company with limited or complete access to your medical records.
I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]
How Do You Write a Release Form? The first step in writing is identifying all parties involved, including the releaser and the release. Specify the activity or event in detail, such as a photo shoot, a video production, or a performance. Clearly specify what is being released, whether liability, claims, or damages.
A release is a contract that terminates all your claims regarding the discharged party. You give up all your claims in exchange for an agreed-upon sum. Once you sign a release agreement, you will be prevented from filing further claims for any injuries, whether known or unknown.
Authorization for Disclosure of Medical or Dental Information (DD Form 2870) Use this form to authorize an individual to release information that is protected under the Federal Privacy Act.