Medical Document Release Form

A medical document release form is a document which outlines the terms and conditions governing the release of a patient from a hospital or a nursing home. The health status of the patient must be clearly mentioned and the hospital’s stand on emergencies that may occur to the patient after release must also be mentioned. This is the most important section of a medical document release form, and it can also be treated as a legal document if the need arises.

You can Download the Free Medical Document Release Form customize it according to your needs and Print. Medical Document Release Form is either in MS Word, Excel or in PDF.

Sample Medical Document Release Form:

Medical Document Release Form

Download Free Medical Document Release Form

The following is the medical release form for Ryan Rogers, aged 34, on the fourth day of June, 2011. The patient was admitted in room number 23, in the orthopedic department. The date of admittance is 23rd May 2011. The following details must be considered.

  • All dues have been cleared
  • Payments have been made by cheque

  • Health status on date of release: The patient, admitted with a fracture in his right tibia, has shown signs of improvement and is out of any risk.
  • Post release prescription: Prescribed separately.
  • Supervising Doctor: Dr. Jason Kent
  • Number of days spent in our facilities: 16
  • Total amount paid: $60,000 USD
  • Presence of insurance cover: Yes [please check attached documents]

The hospital will not take any responsibility for the patient’s well being after his discharge. All terms and conditions of this medical document release form must be carefully understood.

Signature of doctor in charge: ____________________________

Signature of relative: ________________________

Signature of patient: _________________________

Posted in Medical Documents