Free Fillable Authorization to Obtain Medical and Billing Records

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.

Name of person
City of person
Name of Doctor
Name of Law Firm
Beginning date
End Date

We DO NOT collect or save the information you entered




I, ___________________________________________________ of _____________________ _______________________________________________________ the undersigned hereby authorize _______________________________________________ , (the “Doctor”), to give to the law office of ___________________________________________ (“Law Firm”) any and all information in their possession regarding my medical records including all x-rays, CAT scans, and any other information pertinent to my treatment, along with all my Billing Information. I am requesting the records for insurance-related reasons.

I was formerly your patient of during the time period from ________________________ till ___________________________.


I agree that this authorization shall remain valid for one year from the date signed.


Dated this ______ day of ______________________, 20___.







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.


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.