[Your Name] [Street Address] [City, ST ZIP Code] November 20, 2007 [Doctor Name] [Medical Practice or Hospital Name] [Street Address] [City, ST ZIP Code]
RE: Authorization to release medical records for [Your Name], DOB: [your date of birth], SSN: [Social Security Number] Dear [Doctor Name]: I am writing to authorize [Attorney Name or Advocate Name] to obtain my medical records on my behalf. Please release my medical records related to treatment for [medical condition(s)] rendered by you or under your supervision from [date] through [date]. If you have any questions, please call me at [your phone number] or [Attorney Name or Advocate Name] at [Attorney or Advocate phone number]. Sincerely,
[Your Name] cc: