Download Authorization Letter for Release of Medical Records for Free

This Authorization Letter for Release of Medical Reports is in a simple form. Comparing with other authorization forms, this one is pretty simple and relatively casual. You can fill the concrete content in the corresponding position in the light of your conditions. This template is offered for free. If you are in need of this letter, you can visit our website and download it for your reference.

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Laurel'Yan'
[Street'Addre ss]'
[City,'ST''ZIP'Cod e]'
[Date]'
[Doctor'Nam e]'
[Medical'Pra ctice'or'Hosp ital'Name] '
[Street'Addre ss]'
[City,'ST''ZIP'Cod e'
RE:'Release'of'medical'records'for'Laurel'Yan,'DOB:'[da te],'SSN:'[So cial'Security'N umber]'
Dear'[Doctor'Name]:'
Please'release'my'medical'records'related'to'treatment'for'[medical'co nditions]'rendered'by'yo u'or'under'
your'supervision'from'[date]'through'[date].'This'in formation 'will'be'used'to 'further'assist'in 'my'medic al'
care,'and'should'be'mailed'to:'
[Your'Nam e'or'Name 'of'Party'to'Rec eive'Records ]'
[Street'Addre ss]'
[City,'ST''ZIP'Cod e]'
Please'bill'me'for'costs'associated'with'providing'copies'of'my'records,'and'I'will'remit'payment'promptly'
upon'receipt'of'the'records.'
Sincerely,'
Laurel'Yan'
Authorization Letter for Release of Medical Records
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