Free Medical Representative Authorization Letter Template
Medical Representative Authorization Letter
February 27, 2050
Dr. Pearl Bergna
Impactrun Health Clinic
Lincoln, NE 68501
Dear Dr. Bergna,
I, [Your Name], residing at Greensboro, NC 27401, hereby authorize Lance Nader, residing at Durham, NC 27701, to act on my behalf in matters concerning my medical care and related decisions. This authorization includes but is not limited to, the collection and review of my medical records, discussions with healthcare providers regarding my treatment plans, and making necessary healthcare decisions in my best interests.
My representative is fully empowered to access my health information, and I trust their ability to handle such matters with the utmost confidentiality and discretion. This authorization is effective from February 28, 2050, and will remain in effect until February 27, 2051, or until revoked by me in writing.
Please accord my representative the same level of cooperation and assistance as you would for me. For verification purposes, my representative may present identification documents as required.
If you have any questions or require further clarification regarding this authorization, please feel free to contact me at 2222 555 7777 or [Your Email].
Thank you for your prompt attention to this matter.
Sincerely,
[Your Name]
