Free Authorization to Obtain Medical Records & Billing Information

This Authorization to Obtain Medical Records and Billing Information is sent by an attorney to a physician’s office in order to obtain a client/patient’s medical and billing information. This authorization is signed by the client and sets forth the dates of treatment for which the records are being sought. This Authorization must be signed and dated by the client/patient as it remains in effect for one year from the date of signing.

Disclaimer:This was not drafted by an attorney & should not be used as a legal document.


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___.

The forms on this site are provided "As-Is." By using these forms you agree that you are using them at your own risk. Most of the free forms are not prepared by an attorney and may need substantial modification. Additional disclaimers can be found in our Terms of Use.