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No such instrument would be legally binding. First, there's no "release" specified in HIPAA (the main US body of medical privacy law). The doctor can legally release your medical records to another caregiver in order to facilitate your medical care (unless you object to this) without any form.

Releases of medical information that are not for the purposes of healthcare, bill payment or operations, or not in response to court order, subpoena, etc. must be accompanied by an Authorization signed by the patient. This Authorization exactly which information, to whom the release is authorized, for how long this document will remain active, and should specify the reason. The whole idea behind this is that there should be no easy way to circumvent correct PHI control procedures. A signed but not dated authorization is not only ineffective; it acts against the spirit of the law.

So no -- not legal.

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