Sample Medical Records Authorization Letter

September 11, 2001

Dr. Rose Marie R. Medina
Mary Hill Clinic
Balanga City, Bataan

Dear Dr. Medina:

I, Analyn M. Santos, would like to authorize my sister, Kimberly M. Santos to get my personal medical records from your clinic. These records include CT scans, X-ray, and MRI scans. I will be using these records for employment purposes.

My sister will present her ID cards for identification.

Thank you very much!

Sincerely yours,

Analyn M. Santos