Letter of Doctor Authorizing Release of Medical Records

Re. Authorization Letter for Release of Medical Reports for [Name of the Patient]

Dear Staff,  I hope this letter finds you in good health. I am writing to authoritatively approve the release of the clinical reports to [Name of the patient with their visit ID] for the purpose of an insurance claim to his office.

Patient’s Information:

Name: [Patient’s Name]
Date of Birth: [Patient’s Date of Birth]
Clinical Record Number (if appropriate): [XXX-XX-XX]
Date of Diagnosis/Examination: [Date of Consultation]

Date of Conducting Test: [Date]

I, [Doctor’s Name], am the consultant of the mentioned patient, and I thus grant my consent for the release of the complete medical records to [Name of the Patient]. This approval incorporates every single clinical record, test results, imaging reports, discussion notes, discourse synopses, and every other significant clinical data relating to his medical examination from [Date] to [Date] at [Medical Clinic Name].

I understand that the purpose of releasing this data is referred to in the request letter received from the patient, signed by his office authorities and stamped by Human Resources. The sole purpose of releasing these medical reports is to help the patient reimburse the amount of medical expenses he had to bear.

This approval is substantial from [Start Date] to [End Date] and would be void otherwise. I hold the authority to revoke this approval recorded as a hard copy anytime, however, on professional and legal grounds. I comprehend that once the data is revealed, it might not be safeguarded by the security guidelines, of the Medical Coverage Transportability and Responsibility Act (HIPAA).

Please be kind to give the mentioned clinical records to the mentioned party in the office locale or send a post covering the documents in a CONFIDENTIAL envelope.

I earnestly ask you to facilitate the most common way of delivering the clinical records, and not use any means that are unrecognizable according to the clinic’s policies.

Would it be advisable for you to require any extra data or documentation from me to proceed with the release of clinical documents? Please feel free to contact me at [Telephone Number] or write to me at [Email Address].

I value your brief response and acknowledgement of this letter of authorization and your professional obligation to keep the records of the patients confidential in the meantime. I will be grateful to you for your prompt cooperation.

Thank you!

Best Regards,

[Doctor’s Name]
[Doctor’s ID]
[Clinic’s Name]

Letter of Doctor Authorizing Release of Medical Records

Sample -2

Re. Letter of Authorization for Release of Medical Reports and Consultation Documents

Dear [Name],

I am writing this letter to authorize the release of medical reports and consultation documents referring to the medical situation and history of my patient [Patient Name], who is currently studying at [Name of the Institution]. As [Patient Name]’s physician, I am here to propose the confirmation that [he/she] has been under my diligent care and consultation for [mention the duration of treatment].

[Patient Name] has requested their medical records be released to [University Name] to substantiate and get approval for [his/her] application for medical leave. I hereby approve the release of their medical records, which include medical reports dated [Date], consultation documents relating to the patient’s visit dated [Date], an X-Ray image Report, an Ultrasound Report, and an OPG dated [Date]. 

Please find enclosed a copy of the patient’s request letter stamped by university authorities. The letter has been signed by me, which authorizes the release of their medical records to [University Name]. If there are any further questions or concerns, please do not hesitate to contact me at [Phone Number] or write to me directly at [Email Address].

Thank you in advance for doing the needful.


[Doctor’s Name]
[Doctor’s ID Number]
[Clinic Address]

Letter of Doctor Authorizing Release of Medical Records

Simi Karton

Dr. Simi Karton currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health-related information with a straightforward approach.

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