[Your Name, & Address here]
[Recipient Name & address here]
Sub – [Patient’s name whose records are being requested]
Date of Birth – […]
Social Security Number – [……..]
To – [Doctor’s name]
I hereby permit [association’s name] or their agent to check, evaluate and make facsimiles of the psychiatric records like comments, reports, memos, receipts and all communications regarding the tests, exams, cure, findings and health prospectus, and any other thing related to the concerned patient.
All these mental records are sought in connection to [state reasons for records].
This validity of this authorization will be for six months from the signed date. The concerned person may request a copy of this authorization.
The copies of this authorization are as valid as the original.
Signature of patient
Patient Name (please print)
Encl: [Enclosures List here]
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