Many times medical of financial information is need by a doctor or other financial institution to complete treatment or to finalize a financial transaction. In those situations, an Authorization Letter is required for the information to be released. The following is a Sample Authorization Letter for medical records to be released.

Your Name
Your Street Address
City, State, Zip Code

Date MM/DD/YYY

Any Hospital
Street Address
City, State, Zip Code

To Whom It May Concern:

I, William D. Farrow, hereby authorize Any Hospital to release to Aletha Snowhite, MD, the following medical information from my personal medical records: All x-rays, cat scans and other pertinent information regarding my treatment while in Any Hospital on May 15-June 1, 2007. I give my permission for this medical information to be used for the following purpose:  To assist in the diagnosis and treatment my reoccurring pain in my stomach and abdominal area. However, I do not give permission for any other use or re-disclosure of this information.

Full name of Patient 
Signature of Patient
Date of Signature