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: your date of birth, SSN: Social Security Number

Dear Doctor Name:

I am writing to authorize Attorney Name 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 date through date.

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

Sincerely,

Your Name

cc: Recipient Name