Authorization to Release Medical Records
TO: [NAME OF DOCTOR]
RE: [NAME OF PATIENT]
You are hereby authorized and directed to furnish to [NAME AND ADDRESS OF RECIPIENT OF MEDICAL RECORDS] copies of any clinical notes and medical records prepared by you relating to the above patient.
You are requested not to disclose any other information to any other persons without my written authority to do so.
[NAME OF PATIENT]
Top Sample Letters terms:
- Authorization to Release Medical Records
- letter to release medical records
- medical records release letter
- example release letter for lease
- example of a permission to pick of medical records
- cover letter for release of medical records
- consent letter from bank rent to own sample
- authorization to transfer lease land samples
- SMAPLE OF RELEASES OF RECORDS