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Letter to doctor authorizing release of medical records

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

[Street Address]

[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]

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]

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