Sub – [Patient name whose records are being requested]
Date of Birth – […]
Social Security Number – [,,,,]
To: [Doctor’s name]
I hereby give my approval to [receiver of medical records] or their representative to check, evaluate, and make copies of the medical, psychiatric, alcohol and/or drug cure records, related to the above-mentioned.
All the medical, mental, alcohol and/or drug cure records includes, but not limits to, all hospital documentations (memos, notes reports, bills, and communications regarding the tests, exams and treatment and, health prospectus of the undersigned.
These records are being requested for use in the inquiry and assessment of [state law suit here]
This authorization is valid for six months from the signed date. Copies of this authorization are as valid as the original.
Signature of patient
Patient name (please print)
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