Release of Information Form

Patient First Name:

Patient Last Name:

Date of Birth:

Last 4 of SSN:

Address:

Phone Number:


I do hereby request to receive a copy of medical record information by (please select one):

If Fax, Email, other mailing address, or special instructions, please specify below or state not applicable:


The record being requested is of:

If other, please specify:


Date(s) of service:

Specific Information Requested:

If other, please specify:


Reason for Request:

If other, please specify:


The patient gives Wayne County Hospital, Inc permission to release information through verbal request. I attest that I have witnessed the patient’s verbal request.

Thank you for choosing Wayne County Hospital for all your healthcare needs.

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