Writing a Letter of Authorization of Medical Records [with Sample]

If you’re wondering how to ask your healthcare provider to release your medical records, you’ll need an authorization letter. 

Considering that this concerns your medical records, this might seem intimidating or confusing. 

But writing an authorization letter is actually fairly simple. There are about six components or pieces of information that should be included in a request for release of medical records.

1. Your Return Address

Your return address information should be included at the top, left-hand side of the page. 

This information is important because it tells the recipient where to send any additional materials that they feel they need to send you or they might also have their own release form that they would like for you to sign. 

By giving them this information, you don’t have to worry about unnecessary delays due to incomplete contact information.

2. Date of Letter

Place the date that you are sending the letter on the left-hand side just below your return address information. 

This information will tell the medical facility when you sent the letter and will help them organize their processing of your request. 

It’s also useful in case, for some reason, your request is delayed. They will have a better idea of how long you have been waiting.

3. Recipient’s Contact Information

Underneath the date of the letter, type the contact information of the recipient. This will include the person within the facility that will need to process your request. You might need to call ahead of time or find this information, if available, on their website. 

Underneath the recipient’s name, type the company’s name, then the street or P.O. Box address underneath the company name, and the city, state, and zip code underneath the street or P.O. Box address.

Including the specific person who will need to process your request is especially useful in larger medical facilities in case the letter is misplaced or accidently sent to the wrong person. 

By having the exact recipient, if the letter is misdirected, they will be able to find the appropriate recipient more quickly.

4. A Quick Greeting

Include a brief greeting to your recipient such as “Dear Mary Johnson.”

5. Main Paragraph

This is the section where you will clearly state who you are authorizing to release medical records and who they should release those records to. 

In this section you should also give the releasing medical office the mailing information of the office that you would like them to mail your medical records to. 

You will also need to provide your birth date and telephone number. Include a request that they call you if there is anything else that they need or if they have any questions.

6. Closing

Include a brief closing in which you use both your first and last name. The last name is important even if your last name is on the outside envelope for two reasons. The first reason this is important is in case the letter is separated from the envelope. 

Depending on the size of the medical office, they might have had a couple thousand patients with the name of James. The other reason is that this authorization letter serves as a legal document. 

In the case that legal issues were to arise, the authorization letter would serve as proof that the release of medical records were indeed requested.

A final portion of the closing would be to actually sign your name under your closing. The signature is important because, in the case of any legal issues, your signature shows that the letter was not falsified and it was indeed you who requested the medical release.

Below is a sample letter for authorization of medical records.

Sample Letter For Authorization Of Medical Records

1111 Cherry Ln.
Madison, WI 53705

October 12, 2021

Mary Johnson
New Visions Eye Center
789 Elm St.
Madison, WI 53705

Dear Mary,

I authorize New Visions Eye Center to release my complete medical records and mail them to Pathfinder Clinic.

Their address is 1234 Rose Road, Madison, WI 53705. My full name is included at the bottom of this letter. My birthdate is 11/13/1982.

If you have questions or need more information you may call me at (608) 141-1111.


James Smith

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