Sample Authorization Letter On Medical Record Copy Application
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1Authorization Letter On Medical Record Copy Application
I am _________________because of _______________Therefore agree to
appoint______________(Relationship ：
)，to apply my medical
record copy form Far Eastern MH，Please provide me the medical record form
______year____month to______year_____month，(As indicated on the application
form)
Patients Name( or Official Authorization Authorized Person)：
(Signature)
Authorized Persons Signature：_________year _____month_____day
Authorizing Date：_________Year_________Month___________Day
ID copy Attachment(submit patients ，APs ID)
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Parent category: Letters