[Your Name]
[Your Address]
[City, State, ZIP Code]
[Email Address]
[Phone Number]
[Date]

[Healthcare Provider’s Name]
[Healthcare Facility’s Name]
[Facility’s Address]
[City, State, ZIP Code]

Subject: Authorization for Medical Records Release

Dear [Healthcare Provider’s Name],

I, [Your Name], residing at [Your Address], hereby authorize [Healthcare Facility’s Name] to release the following medical records to [Recipient’s Name], residing at [Recipient’s Address]:

  1. [Specific Record 1]
  2. [Specific Record 2]
  3. [Specific Record 3]

This authorization is effective from [start date] to [end date] and includes the authority to obtain copies of all relevant medical records. The purpose of this authorization is to facilitate the management of my healthcare needs during my absence due to [reason, e.g., travel, work commitments, health issues].

Attached are copies of my identification and [Recipient’s Name]’s identification for verification purposes. Should you require any further information or have any questions, please contact me directly at [your phone number] or [your email address].

Thank you for your cooperation.

Sincerely,
[Your Name]
[Signature]
[Witness’s Name]
[Witness’s Address]
[Witness’s Signature]