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文档名称：

letter of authorization

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authorization,letter (点此参考锦日网其他相关内容)

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/Office Word

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游客

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Frank.Brown

整理时间：

07-05

下载次数：

165

文档简介：

Your Name
Your Street Address
City, State, Zip Code

Date (MM/DD/YYY)

Any Hospital
Street Address
City, State, Zip Code

To Whom It May Concern:

I, William D. Farrow, hereby authorize [Hospital Name] to release to Aletha Snowhite, M.D., any information in my personal medical records, including all x-rays, cat scans, and any other information pertinent to my treatment while I am under the care of [Hospital Name] during the time period from May 15 to June 1, 2007. I give my permission for this medical information to be used for the following purpose: to assist in the diagnosis and treatment of my reoccurring abdominal pain. I do not, however, give permission for any other use or for any re-disclosure of this information.

Full name of Patient
Signature of Patient
Date of Signature

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