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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