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sample letter authorization to release medical records

Sample Authorization to Release Medical records Letter

by emily on March 3, 2012

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.
Dated: _______________

_____________________________________
Signature of patient

_____________________________________
Patient name (please print)

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Sample Authorization to Release Medical Records Letter

by emily on February 25, 2012

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]

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Sample Authorization to Release Employment Records Letter

by emily on March 3, 2012

Sub – [Patient’s name whose records are being requested]

 

Date of Birth – [….]

Social Security Number  –  [no.  Here]

 
To: [Doctor’s name]

 

I hereby give permission to [individual/association name to receive medical records] or their agent for checking, evaluating and making facsimiles of all the medical, mental, psychiatric, alcohol and/or drug treatment records for the undersigned.

 

All such records will include (not limited to) all hospital records, memos, observations, reports, bills, and communications regarding the medication, tests, findings and health prospects of this patient.

 

These records are required to testify for the   – [state type of lawsuit] –.

 

The validity of this authorization is for six months from the signed date.

 

Photo copies of this authorization are as legitimate as the original.
Dated: _______________

_____________________________________
Signature of patient

_____________________________________
Patient name (please print)
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Sample Authorization to Release Employment Records Letter

by emily on March 3, 2012

Sub – [Employee name, records are being requested for]

Date of Birth:  –   […]
Social Security Number: [no. here]

 

To: [Designation]

[Company name]
I hereby give permission to [organization’s name] or their representative to examine, analyze, and create copies (including photo static copies) of all staff, job, medical and payroll records related to [employee name for whom, records are being requested].

 

The photo static copies will be considered as official as the original for this authorization.
Dated: _______________

_____________________________________
Employee signature

_____________________________________
Employee name (please print)

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Sample Authorization Letter

by emily on December 28, 2011

Hospital or Doctor’s Name:

Address:

Date:

To Whomsoever It May Concern:

I, (Patient Name), hereby authorize (Hospital’s Name) to release to (Person’s Name or Name of the Doctor with his designation), any information in my personal medical records, reports and any other information relevant to my cure while I am under the care of (Hospital’s Name) during the time period from (Admission date to discharge date). (The opening lines are very significant part of an authorization letter. All the points, names, dates, and all instructions should be clearly mentioned).

I hereby give my permission for this medical information to be used for the following purpose: (mention purpose). (Make sure that specific instructions are given so that there is no confusion later. Tone of the letter should be kept formal as it is a business letter.)

Yours Sincerely,

Patient’s Name

Patient’s Signature

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