Sample Authorization to Release Medical Records Letter

Authorization to Release Medical Records –

MEDICAL APPROVAL

TO:  [Doctor’s Name]

RE:  [Patient’s Name]

You are hereby authorized to provide [Name & address of person to receive medical records] with copies of any medical tests & exams conducted by you for the patient mentioned above.Please do not disclose any information to any person without our written approval.

Dated: […]

_______________________________

[Patient Name]

Download Sample Authorization to Release Medical Records Letter In Word Format

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