Release of Information Letter
[YOUR NAME]
[YOUR EMAIL]
September 30, 2050
Dr. Ernest Will
Chief Physician
ArcoSoft
Detroit, MI 48201
Subject: Release of Information for Medical Records
Dear Dr. Will,
I, [YOUR NAME], born on March 15, 1980, hereby authorize the release of my medical records as detailed below. This release is intended to allow my healthcare providers and authorized family members to access my medical information as necessary for my continued care and treatment.
1. Patient Information
Patient Name: [YOUR NAME]
Date of Birth: March 15, 1980
Medical Record Number: 789456123
Phone Number: 222 555 7777
Address: Chicago, IL 60631
2. Information to be Released
I authorize the release of the following information:
3. Recipient Information
This information is to be released to:
Recipient Name: Arnaldo Feest
Relationship to Patient: Spouse
Recipient Contact Information: 222 555 7777
Recipient Address: Chicago, IL 60631
4. Purpose of Release
The purpose of this release is to facilitate my ongoing medical care and treatment. I understand that my information may be shared among my healthcare providers and authorized family members to ensure the continuity of my care.
5. Authorization and Expiration
This authorization will remain in effect until September 30, 2051, unless I revoke it earlier in writing. I understand that I have the right to revoke this authorization at any time by providing a written notice to Springfield Medical Center.
Signature
By signing below, I confirm that I am authorizing the release of my medical records as outlined in this letter.
[YOUR NAME]
Sincerely,
[YOUR NAME]
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