Re: <name of patient whose records are being sought>
Date of Birth: <date of birth of patient>
Social Security Number: <social security number>
To: <name of doctor or hospital>
I hereby authorize <name of party or parties to acquire medical records> or their agent or representative, to inspect, review, and make copies, including photostatic copies, of all medical, psychiatric, psychological, alcohol and/or drug treatment records, pertaining to the undersigned. Said medical, psychiatric, psychological, alcohol and/or drug treatment records shall include, but not be limited to, all hospital records, memorandum, notes, reports, billings, and correspondence concerning the care, treatment, examination, testing, diagnosis and prognosis of the undersigned. These records are to be used in the investigation and evaluation of <describe the nature of your lawsuit>. This authorization shall remain valid for six months from the date of signature. Photostatic copies of this authorization are to be considered as valid as the original.
Dated: _______________
_____________________________________
Signature of patient
_____________________________________
Patient name (please print)
Download authorization to release medical records in Word Format