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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. 
 Full name of Patient  
 Signature of Patient 
 Date of Signature