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Free Fillable Authorization to Obtain Medical and Billing Records Generator

This is a great form. You can do a lot with it. But sometimes you want more, like instructions, examples, different formats, editable and of course attorney prepared. You can find one of those with this Authorization to Obtain Medical and Billing Records for just a few dollars.

Child Name
Child Age
Birth Date
Child Address
Social Security Number
School or Organization Name
Grade Level
Parents or Guardians Names
Parents or Guardians Address
Parents or Guardians Phone Numbers
Parents or Legal Guardians Names
Name of Child
Organizer Name
Beginning Date of Permission for Participation
End Date of Permission for Participation
Expiration Date of Authorization
Medical Insurance Company Name and Address
Medical Insurance Company Telephone Number
Insurance Policy or Group Identification Number
Emergency Phone Number
Allergies or Medical Conditions


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HTML Authorization to Obtain Medical and Billing Records

Parental Permission Medical Consent and Liability Release

 

CHILD�S NAME: ____________________________

AGE: _____________________________________

BIRTH DATE _______________________________

ADDRESS__________________________________

__________________________________________

SOCIAL SECURITY# ___________________________

SCHOOL ___________________________________

GRADE ____________________________________

 

PARENT(S)/GUARDIAN NAME(S)

�__________________________________________

___________________________________________

PHONE(S)___________________________________

___________________________________________

 

TO WHOM IT MAY CONCERN:

 

I/We, of _____________________________________________________ the parent(s) or legal guardian(s) of the Participant do/does hereby give permission for the following child: _____________________________________________________ ____________________________________ (�Participant�), to attend and participate in sports, events, and retreats (�Events�) held by _____________________________________ (�Organizer�) during ____________________________ to _____________________________.�

 

LIABILITY RELEASE

In consideration of Organizer allowing the Participant to participate in the Events, I/we do hereby release, forever discharge and agree to hold harmless Organizer, its directors, employees, volunteers and agents from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by Participant while involved in the Events, other than in incidents considered to be gross negligence.

Furthermore, I/we hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in the Events.

 

MEDICAL TREATMENT CONSENT:� I/We authorize the Organizer to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. I agree to be liable and to pay all costs and expenses incurred in connection with such medical and dental services rendered to the Participant pursuant to this authorization.

 

This authorization shall remain effective through the day of , 20 , unless sooner terminated in writing.

 

DETAILS:

 

Medical Insurance:� ___________________________________________

Insurance Company: __________________________________________

Policy/Group ID#: ____________________________________________

� Emergency Phone Number:� ___________________________________________________________

___________________________________________________________

Allergies or Medical Conditions: ___________________________________________________________

___________________________________________________________

 

Parent/Guardian Signatures

_______________________________/_________________________________ Date ___________

Description

When you need to get medical and billing records from a doctor to give to your attorney who is handling a case for you, it is necessary to use an Authorization form. This Authorization to Obtain Medical Records and Billing information instructs your Doctor to release your medical records for the dates indicated in the release.







Instructions

Simply fill out the fields on this page with the required information. Press the "Create Form" button. If you want a blank form, leave the fields as they are and click on the 'Create Form' button. On the next page you will be able to download your completed form. The form can then be edited further or just printed. That's all there is too it. We do not collect or save any of the information you enter in these forms. The information is solely used to fill out the form you are preparing.

Disclaimer: This form was not drafted by an attorney and is provided "As-Is" and may need substantial modifications to be valid. It should not be used as a legal document. By using any form on this site you agree that you are using them at your own risk.