Medical or financial information is often required by a doctor or financial institution in order to administer treatment or to finalize a transaction. In such situations, you must write an authorization letter in order to release the information. The following letter is a sample authorization letter for releasing medical records.

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 [Hospital Name] to release to Aletha Snowhite, M.D., any information in my personal medical records, including all x-rays, cat scans, and any other information pertinent to my treatment while I am under the care of [Hospital Name] during the time period from May 15 to 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 of my reoccurring abdominal pain. I do not, however, give permission for any other use or for any re-disclosure of this information.