Authorization Letter for Medical Records

Robert Terry
456 Elm Street
Rochester, NY 14620
[email protected]
(585) 555-1234
February 16, 2024

Rochester General Hospital
Medical Records Department
1425 Portland Avenue
Rochester, NY 14621

Subject: Authorization for Release of Medical Records

Dear Medical Records Department,

I, Robert Terry, born on July 9, 1980, hereby authorize Rochester General Hospital to release and provide copies of my medical records to Dr. Lisa Hamilton, my designated physician, who is located at 789 Medical Plaza, Rochester, NY 14623.

The purpose of this authorization is for continuing medical care as I am transitioning to Dr. Hamilton’s practice due to a recent move.

Please include the following specific information in the release:

  • All medical notes and reports from January 1, 2020, to December 31, 2023.
  • Laboratory test results, including blood work and imaging studies (X-rays, MRIs, CT scans) conducted within the same period.
  • Treatment plans and summaries for any ongoing or past conditions.
  • Any other records pertinent to my medical history and treatment during the specified period.

This authorization is valid from February 16, 2024, until August 16, 2024. I understand that I have the right to revoke this authorization at any time by providing written notice to Rochester General Hospital. I also acknowledge that until this revocation is submitted, my medical provider is authorized to release my medical records as specified.

I am aware that the information released as per this authorization could be subject to re-disclosure by the recipient and might not be protected by federal privacy regulations.

Should you require any further information or verification, please contact me at (585) 555-1234 or [email protected].

Thank you for your prompt attention to this matter.

Sincerely,

[Signature of Robert Terry]
Robert Terry

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