Medical Decision Authorization Letter

Last Updated: May 7, 2024

Medical Decision Authorization Letter

Olivia Erickson
123 Healing Way
Wellness City, WV 34567
[email protected]
October 12, 2023

To Whom It May Concern,

I, Olivia Erickson, residing at 123 Healing Way, Wellness City, WV, do hereby authorize Dr. Sophia Martin, and in her absence, any medical professional designated by her, to make any and all decisions regarding medical treatment for my health, including but not limited to surgical interventions, medical procedures, medication administration, and any other treatment or procedure deemed necessary for my well-being, in the event that I am unable to make such decisions for myself.

This authorization includes access to my medical records for the purpose of making informed decisions about my health care. It is my intention that this letter be used to help in my treatment and to ensure that my health care preferences are respected.

I understand the implications of this authorization and affirm that this decision has been made freely, without any duress or coercion. This letter is valid immediately and will remain in effect until further notice. I reserve the right to revoke this authorization at any time, provided that any revocation will be made in writing.

For verification purposes, my date of birth is April 9, 1985, and my social security number is 123-45-6789.

Should any further information be required, please do not hesitate to contact me directly at the phone number or email address listed above.

Thank you for your attention to this matter and for your cooperation in ensuring my health care wishes are fulfilled.



Olivia Erickson

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