Free Professional Medical Release Letter Template
Professional Medical Release Letter
[Your Name]
[Your Address]
[Your Email]
[Your Phone Number]
December 15, 2052
To Whom It May Concern,
I, [Your Name], hereby authorize the release of my medical records and health information to Dr. Jane Smith, Anytown Medical Center, as requested to continue care and treatment.
This release includes but is not limited to, all medical records, diagnosis information, treatment plans, prescriptions, laboratory results, and any other documents related to my healthcare and medical history, including those related to mental health or substance abuse treatment, if applicable.
I understand that this information will be shared by the Health Insurance Portability and Accountability Act (HIPAA) regulations and that I have the right to revoke this authorization at any time in writing.
I further acknowledge that the information being released may contain sensitive or confidential details, and I consent to the disclosure of such information to the named recipient. I understand that the recipient may use this information for purposes related to my medical care or as required by law.
This release will remain valid until December 15, 2053, unless otherwise revoked.
Please do not hesitate to contact me if you need further information or clarification.
Thank you for your attention to this matter.
Sincerely,
[Your Name]
