Authorization Letter Sample for Release of Medical Records
Your Name
Your Street Address
City, State, Zip Code
Date (MM/DD/YYY)
Name of Hospital or Doctor
Street Address
City, State, Zip Code
To Whom It May Concern:
I, (Your Name), hereby authorize (Hospital Name) to release to (Name of Person or Doctor with his qualification), any information in my personal medical records, including all x-rays, CAT scans, and any other information pertinent to my treatment while I am under the care of (Hospital Name) during the time period from (Date of admission till date of discharge). I give my permission for this medical information to be used for the following purpose: to assist in the diagnosis and treatment of my reoccurring abdominal pain. I do not, however, give permission for any other use or for any re-disclosure of this information.
Full name of Patient
Signature of Patient
Date of Signature