[Your Name]

[Street Address]

[City, ST ZIP Code]

[Date]

[Doctor Name]

[Medical Practice or Hospital Name]

[Street Address]

[City, ST ZIP Code

RE:	Request for privacy/non-release of medical records for [Your Name]
DOB: [date], SSN: [Social Security Number]

Dear [Doctor Name]:

I am writing to request that you do not release any of my medical records that are in your possession to anyone without my permission. This includes but is not limited to other health care agencies, medical licensing boards, government agencies, or any person representing or acting on behalf of any of these.

If you receive any request or demand for my medical records, please let me know promptly.

I also request that you place this letter in my medical records file.

Sincerely,

[Your Name]