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Authorization letter for release of medical records

Description

Authorize the release of your private medical records to another physician or organization with this letter template. The letter offers to pay for the copying costs.

User
[Street Address]
[City, ST  ZIP Code]
[Date]

[Doctor Name]
[Medical Practice or Hospital Name]
[Street Address]
[City, ST  ZIP Code

RE: Release of medical records for User, DOB: [date], SSN: [Social Security Number]

Dear [Doctor Name]:

Please release my medical records related to treatment for [medical conditions] rendered by you or under your supervision from [date] through [date]. This information will be used to further assist in my medical care, and should be mailed to:
[Your Name or Name of Party to Receive Records]
[Street Address]
[City, ST  ZIP Code]
Please bill me for costs associated with providing copies of my records, and I will remit payment promptly upon receipt of the records.
Sincerely,
User

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