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 of Hospital) during the time period from (Date of admission till date of discharge). (The first paragraph is the most important part of an authorization letter. It must be to the point and contain all the exact instructions, name of the parties and date and any other point that needs to be mentioned to make matters clear.)
I give my permission for this medical information to be used for the following purpose: (mention purpose). (Make sure that specific instructions are given so that there is no confusion later. Keep the tone formal as it is a business letter.)
Sincerely,
Name of Patient
Signature of Patient