[Date]
[Doctor Name]
[Medical Practice or Hospital Name]
[Street Address]
[City, ST ZIP Code
RE: Release of medical records for User , DOB: [date] , SSN: [Social Security Number]
Dear [Doctor Name] :
Please release my medical records related to treatment for [medical conditions] rendered by you or under your supervision from [date] through [date] . This information will be used to further assist in my medical care, and should be mailed to:
[Your Name or Name of Party to Receive Records]
[Street Address]
[City, ST ZIP Code]
Please bill me for costs associated with providing copies of my records, and I will remit payment promptly upon receipt of the records.
Sincerely,
User