Description
Use this letter to authorize your health care provider to release your private medical records to the person(s) you specify.
[Your Name]
[Street Address]
[City, ST ZIP Code]
[Doctor Name]
[Medical Practice or Hospital Name]
[Street Address]
[City, ST ZIP Code]
RE: Authorization to release medical records for [Your Name] , DOB: [date of birth] , SSN : [Social Security Number]
Dear [Doctor Name] :
I am writing to authorize [Attorney 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 [start date] , through [end date] .
If you have any questions, please call me at [phone number] or [Attorney or Advocate Name] at [attorney or advocate phone number] .
Sincerely,
[Your Name]
cc: [Attorney or Advocate Name]
