Medical Authorization Letter
Medical Authorization Letter
[YOUR NAME]
[YOUR EMAIL]
August 8, 2050
To Whom It May Concern,
I, [YOUR NAME], hereby authorize the release of my medical records to the following individual or organization:
Recipient Information:
Name: Dr. Laura Mitchell
Organization: Greenfield Medical Center
Contact Number: 727-828-5803
Email Address: [email protected]
Purpose of Authorization: Granting Access to Medical Records
Scope of Authorization:
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Access to all medical records, including but not limited to medical history, test results, and treatment information.
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Authorization to discuss and obtain information related to my medical care.
Effective Dates: This authorization is valid from August 8, 2050, to August 8, 2051.
Additional Notes:
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This authorization may be revoked at any time by providing written notice to the healthcare provider.
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The release of medical records will be in accordance with applicable privacy laws and regulations.
Please contact me at [YOUR EMAIL] or 786-200-3351 if you require any further information or clarification regarding this authorization.
Thank you for your attention to this matter.
Sincerely,
[YOUR NAME]
[YOUR EMAIL]