AUTHORIZATION LETTER TO RELEASE INFORMATION
August 9, 2050
To Whom It May Concern,
I, [Your Name], hereby authorize Greenwood Medical Clinic, located at 2764 Hershell Hollow Road, Anaheim, CA 92805, to release my medical records to Floyd Cremin, whose contact details are as follows: 3723 Ashcraft Court, Lakeside, CA 92040.
This authorization includes the release of all medical records, including but not limited to:
Medical History: Detailed records of past diagnoses, treatments, and consultations.
Treatment Records: Documentation of all treatments, medications, and procedures received.
Diagnostic Reports: Results of any diagnostic tests, imaging, or laboratory reports.
Physician Notes: Any notes or observations made by my healthcare providers.
The purpose of this release is for insurance purposes. This authorization is valid from the date of this letter until December 31, 2050.
I understand that I have the right to revoke this authorization at any time by providing a written notice to Greenwood Medical Clinic. However, any revocation will not affect information that has already been released under this authorization.
Please contact me directly at [Your Email] if you require any additional information or have any questions regarding this authorization. Thank you for your prompt attention to this matter.
Sincerely,
[Your Name]
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