1234, Main Street
Boston, MA 02123
05 April, 2005
<Recipient Address Goes Here>
Hello,
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 psychiatric records including, but not limited to, all memorandum, notes, reports, billings and correspondence concerning the care, treatment, examination, testing, diagnosis and pronosis of the undersigned. These psychiatric/psychological records are to be used in the investigation and evaluation of <reason records are needed>. This authorization shall remain valid for six (6) months from the date of signature. Upon request, the undersigned may have a copy of this authorization. Photostatic copies of this authorization will be considered as valid as the original.
Dated: _______________
_____________________________________
Signature of patient
_____________________________________
Patient Name (please print)
Regards,
Robert Anderson
encl: <List of enclosed items goes here>
Download authorization to release psychiyatric or psychological records In Word Format