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)
Download Sample Authorization to Release Employment Records Letter In Word Format 1