doctor
Post on 12-Jan-2016
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DESCRIPTION
med record
TRANSCRIPT
[Your Name]
[City, ST ZIP Code][Date]
[Doctor Name][Medical Practice or Hospital Name][Street Address][City, ST ZIP Code]
RE: Authorization to release medical records for DOB: , SSN:
Dear :
I am writing to authorize to obtain my medical records on my behalf. Please release my medical records related to treatment for rendered by you or under your supervision from through .
If you have any questions, please call me at or at .
Sincerely,
[Your Name]
cc:
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