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Authorization Letter for Release of Medical Records


Authorization Letter for Release of Medical Records
Laurel'Yan'
[Street'Addre ss]'
[City,'ST''ZIP'Cod e]'
[Date]'
[Doctor'Nam e]'
[Medical'Pra ctice'or'Hosp ital'Name] '
[Street'Addre ss]'
[City,'ST''ZIP'Cod e'
RE:'Release'of'medical'records'for'Laurel'Yan,'DOB:'[da te],'SSN:'[So cial'Security'N umber]'
Dear'[Doctor'Name]:'
Please'release'my'medical'records'related'to'treatment'for'[medical'co nditions]'rendered'by'yo u'or'under'
your'supervision'from'[date]'through'[date].'This'in formation 'will'be'used'to 'further'assist'in 'my'medic al'
care,'and'should'be'mailed'to:'
[Your'Nam e'or'Name 'of'Party'to'Rec eive'Records ]'
[Street'Addre ss]'
[City,'ST''ZIP'Cod e]'
Please'bill'me'for'costs'associated'with'providing'copies'of'my'records,'and'I'will'remit'payment'promptly'
upon'receipt'of'the'records.'
Sincerely,'
Laurel'Yan'
Authorization Letter for Release of Medical Records