Authorization Letter for Release of Medical Records (Sample)

This is an authorization from a person (patient) - who was earlier being treated in a hospital or any medical institution. Here, authorization is given by him to another person or organization to get the medical reports related to his health treatment done earlier in that hospital.

For the obvious reasons that without a signed authorization the hospital would not share such confidential information of a previous patient.

The patient can provide authorization for release of whole or limited information related to his earlier health treatment.

Following format could be modified suitably as per your need.

TEMPLATE

Date: ................

To

(Name of the Hospital)

(Address)

(Phone Number)

Sub.: Authorization for release of my medical /health related information

Dear Sir/Madam,

I was a patient earlier being treated in your hospital last year. Now I am undergoing some medical treatment in the (Name of the Medical Institution). My doctors have informed me that they would need to refer some of the medical reports from the treatment I had undergone at your hospital previously.

Since I am unable to trace those documents at my home or anywhere else, I would kindly request you to provide them the copies of my medical records, which will help me in my current treatment.

In order for you to trace my medical reports - I am providing herewith the following information for your ready reference.

Name: .......................................

Date of birth: .................

Address: ....................................

Phone No.: .....................

Email id: ....................................

Admitted to hospital: (Date) or (Month, Year)

Discharged from hospital: (Date) or (Month, Year)

Health information to be released: (All reports and tests documents) or (Limited - Write the name of the particular medical report).

I hereby authorize your hospital i.e. (Name) to release the medical reports as mentioned above to the (Name of the Medical Institution) as and when approached by them at the earliest possible after that.

I understand that these information and documents related to my health are personally identifiable protected health information and I will not hold (Hospital's Name) responsible for any claim in future. I take full responsibility for release of such information.

This authorization will remain in force until (Date). I reserve the right to revoke the authorization at any time through a written notice.

I am enclosing herewith a self-attested copy of my identity and address proof for your verification purposes.

Kindly do the needful and oblige.

Thanking you,

Yours sincerely,

   (signature)

(Name of the Person/Patient)

Encl.: As above