Your Name

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 Your Name, 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,

Your Name