Medical Authorization Release Letter

Use this letter format when you want to authorize a medical office to release your medical records to another medical office. Ask the releasing medical office what information your letter should include, such as your full name and date of birth. In the letter be sure to give the releasing office the full name and address of the medical office to which your records are being sent. Customize this letter according to your specific needs.

[Your letterhead, if desired; if not, your return address]

[Date of letter-month, day, and year]

[Recipient's first and last names]
[Company name]
[Street or P.O. box address]
[City, State ZIP code]

Dear [recipient's name]:

I authorize Village Orthopedics to release my complete medical records and send them via mail to Orthopedics on Broadway. Their address is 2500 Broadway Street, Minneapolis, MN, 55402. My full name is included at the bottom of this letter, and my date of birth is 12/5/75.

Please send the records as soon as possible. You may call me at 350-555-1213 if you have questions or need further information.

Thank you for your prompt attention to this matter.

Best regards,

[Signature]

[Sender's first and last names]

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