Sample Template Example of Letter To Doctor From Patient in Word / Doc / Pdf Free Download
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PERMISSION / AUTHORIZATION LETTER FORMAT TO DOCTOR REGARDING RELEASE OF PATIENT’S MEDICAL RECORDS
MEDICAL AUTHORIZATION
TO: [NAME OF DOCTOR]
RE: [NAME OF PATIENT]
You are hereby authorized and directed to furnish to [NAME AND ADDRESS OF RECIPIENT OF MEDICAL RECORDS] copies of any clinical notes and medical records prepared by you relating to the above patient.
You are requested not to disclose any other information to any other persons without my written authority to do so.
Dated: [DATE]
_______________________________
[NAME OF PATIENT]
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