Sample Medical Records Search Letter Page 2
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1
2AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
TO: Insert Name and Address of Hospital or Physician's Office
This authorizes physicians, hospitals, and all medical providers to furnish
full and complete medical records and reports and any other information
hereby requested by the undersigned to:
________________
(Your Name)
________________
(Your Address)
________________
________________
_
PATIENT (Mom's name)
Soc. Sec. #:
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