Letter to doctor authorizing release of medical records
9/07/2017
Description
Send this letter template to your health care provider as an authorization to release your private medical records to the person you specify.
User
[City, ST ZIP Code]
[Date]
[Doctor Name]
[Medical Practice or Hospital Name]
[Street Address]
[City, ST ZIP Code]
RE: Authorization to release medical records for User
DOB:[your date of birth] , SSN: [Social Security Number]
DOB:
Dear [Doctor Name] :
I am writing to authorize [Attorney Name or Advocate Name] to obtain my medical records on my behalf. Please release my medical records related to treatment for [medical condition(s)] rendered by you or under your supervision from [date] through [date] .
If you have any questions, please call me at [your phone number] or [Attorney Name or Advocate Name] at [attorney or advocate phone number] .
Sincerely,
User
cc: [Recipient Name]
