[Your Name]

[Street Address]

[City, ST ZIP Code]

[Date]

[Doctor Name]

[Medical Practice or Hospital Name]

[Street Address]

[City, ST ZIP Code]

RE:	Authorization to release medical records for [Your Name], DOB: [date of birth], SSN: [Social Security Number]

Dear [Doctor Name]:

I am writing to authorize [Attorney or Advocate Name] to obtain my medical records on my behalf. Please release my medical records related to treatment for [medical condition(s)] rendered by you or under your supervision from [start date], through [end date].

If you have any questions, please call me at [phone number] or [Attorney or Advocate Name] at [attorney or advocate phone number].

Sincerely,

[Your Name]

cc: [Attorney or Advocate Name]