Authorization Letter for Release of Medical Records (Template)

This is an authorization from a person (patient) - who was earlier getting 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 the earlier health treatment 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 template could be modified suitably as per your need.

FORMAT

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

To

(Hospital Name)

(Address)

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

Dear Sir/Madam,

I was a patient earlier getting treated in your hospital last year. Now I am undergoing some medical treatment in the (hospital/ medical institution name). My doctors have informed me that they would need to refer some of the medical reports from the treatment I had 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 copies of the medical reports 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 - name of the medical report only).

I hereby authorize your hospital i.e. (name) to release the medical reports as mentioned above to the (hospital/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 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 before that upon a written notice to you.

Kindly do the needful and oblige.

Thanking you!

Sincerely,

signature

(Name of the Person/Patient)

(Sample) Authority Letter to Pick up My Medical Result Report

A person may not always be in a situation to collect his medical test's result reports from the hospital/medical institution. In that case, he can very well authorize someone else on his behalf to pick up the documents for him.

Two things could be very important here - to make it work:
(1) The person, who is authorizing, should give his self attested copy of any identity proof;
(2) The authorized person should carry his original identity proof as well as a self attested copy.

These will help the hospital/medical institution to verify the authenticity of both the person and would enable them to give the medical reports without any hesitation.

Modify the following format suitably.

FORMAT

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

From

(Name of the Person)

(Resident Address)

(Tel. No. ..............)

(Email id. ...............)

To

(Name of the Officer)

(Designation)

(Name of the Hospital/Medical Institution)

(Address, Tel. No. ............)

Sub.: Authority to collect medical results on my behalf

Dear Sir/Madam,

I had recently undergone some medical tests at your hospital/clinic as advised by my doctor. Following are my personal and tests details for your kind reference.

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

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

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

Medical tests done on (date)

The payment acknowledgement copy is enclosed herewith.

I am presently very sick and hence I am not in a position to visit your hospital/clinic personally to collect the report on the medical tests results done on me that day.

Therefore, I am hereby authorizing the following person who will collect the documents on my behalf.

Authorized Person's Name: ..................

Signature: ...............

He will be visiting the hospital/clinic tomorrow to collect the medical reports. Kind request to your goodself to please hand over the necessary documents and certificates to him without fail.

A copy of my identity proof self attested by me is enclosed herewith for verification purposes.

Thanking you for your cooperation!

Yours faithfully,

  signature

(Name of the Person)

Encl: A/a