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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Authorization Letters
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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