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Morris County Adjuster's Office

PO Box 900 Morristown, NJ 07963-0900

(973) 285-6486

Patient Medical Records Release

Patient Name


I am the patient, or the legally authorized representative of the patient listed above. I authorize the custodian of records to release my protected health information (or the patient information listed above) to:

Person/Company/Organization Address

(Note: If these records contain any information from previous providers or information about HIV/AIDS or communicable disease including sexually transmitted disease, cancer diagnosis, drug/alcohol abuse, or genetic information, you are hereby authorizing disclosure of this information.)

I understand that after the custodian of records discloses my health information, it may no longer be protected by federal privacy laws. By signing below, I represent and warrant that I have authority to sign this document and authorize the user or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected health information.

Signature of patient or authorized representative

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Printed name of patient or authorized representative


Photo identification issued by a government agency certifying my identity

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