Name of Hospital or Doctor: Address: Date: To Whom It May Concern: I, (Your Name), hereby authorize (Name of Hospital) to release to (Name of Person or Doctor with his designation), any information in my personal medical records, reports and any other information pertinent to my treatment while I am under the care of (Name […]
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Letter of Authorization Form
To, Recipient’s name: Recipient’s address: Date: I hereby authorize the use and disclosure of any health information as mentioned below. I would like to set forth that I may revoke this authorization at any time by notifying the medical practice. In the event of revocation of this authorization, there will not be any affect on […]
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Sample Authorization to Debit Account Letter
AUTHORIZATION TO DEBIT ACCOUNT [DATE, ex. Wednesday, June 11, 1998] [NAME, Bank AND ADDRESS, ex. John Smith XYZ Bank 1234 First Street Suite 567 Anycity, Anystate 85245] Dear [NAME, ex. John Smith], You are hereby authorized and directed to debit our account no. [ACCOUNT NUMBER, ex. 12345678] in the amount of [AMOUNT OF DEBIT, ex. […]
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Photo and Recording Release
RELEASE For good and valuable consideration, the receipt of which is hereby acknowledged, I hereby consent to the photographing of myself and the recording of my voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. I understand that […]
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Commitment Form (Advertising)
COMMITMENT FORM CLIENT:_________________________ DATE_________________ DESCRIPTION ART WORK FOR BILLBOARD DESIGN: Includes conceptual layouts, comprehensive layout, artist’s renderings, preparation of camera – ready mechanicals. Estimated cost $250.00 (Typography costs are extra) This commitment form is to serve as Client’s written authorization for (firm) to perform services and/or contract with suppliers for the above described items or […]
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