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:

Access to all medical records, including but not limited to medical history, test results, and treatment information.
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:

This authorization may be revoked at any time by providing written notice to the healthcare provider.
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,