Sample Authorization Letter

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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