[Your letterhead, if desired; if not, your return address]
[Date of letter-month, day, and year]
[Recipient's first and last names]
[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.
[Sender's first and last names]