7 Best Authorization Letters to Collect Medical Records (Free Templates)

1. General Authorization to Collect Medical Records

[Your Full Name]
[Street Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Facility Address]
[City, State ZIP]

Subject: Authorization to Release and Allow Pickup of Medical Records

Patient: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]
Medical Record Number or Last 4 of SSN: [Optional]

I authorize [Authorized Person’s Full Name], my [Relationship], to pick up and receive copies of my medical records from [Facility or Provider Name]. Acceptable identification will be presented at pickup.

Records requested: [Type of records such as complete chart, physician notes, lab results, imaging, billing statements], covering dates of service from [Start Date] to [End Date]. Purpose of disclosure: [Personal use, continuity of care, insurance, legal review].

Delivery preference: Paper copies for in person pickup by the authorized person. If available, you may also provide a secure electronic copy to [Secure Email] or via patient portal.

I understand this authorization is voluntary and remains effective until [Expiration Date, usually 90 days from signature], unless revoked in writing earlier. I understand that treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this authorization. I understand that information disclosed may be subject to redisclosure and may no longer be protected by HIPAA.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

If signed by personal representative, describe authority: __________________________

Enclosures: Copy of patient photo ID; copy of authorized person photo ID

2. Parent Authorization to Collect a Minor’s Medical Records

[Parent or Legal Guardian Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Release and Pickup of Minor’s Records

Minor Patient: [Child’s Full Name]
Date of Birth: [MM/DD/YYYY]
Parent or Legal Guardian: [Your Name]
Relationship: [Mother, Father, Legal Guardian]

I authorize [Authorized Person’s Full Name], my [Relationship to child], to pick up and receive copies of the medical records for the above named minor from [Facility or Provider Name]. The authorized person will present valid photo identification at pickup.

Records requested: [Well visits, immunization records, specialist notes, lab results], for dates of service [Start Date] to [End Date]. Purpose: [School enrollment, camp, second opinion, continuity of care].

This authorization remains valid until [Expiration Date], unless revoked in writing. I certify that I am the parent or legal guardian with authority to authorize this release. I understand the disclosures may include sensitive information permitted under applicable law.

Signature of Parent or Legal Guardian: _____________________ Date: ________
Printed Name: __________________________
Legal authority if guardian: [Court order, guardianship papers]

Enclosures: Copy of parent or guardian photo ID; proof of guardianship if applicable; copy of authorized person photo ID

3. Spouse Authorization to Collect Medical Records

[Patient Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Release and Pickup by Spouse

Patient: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]

I authorize my spouse, [Spouse’s Full Name], to pick up and receive my medical records from [Facility or Provider Name]. A government issued ID will be provided at the time of pickup.

Records requested: [Type of records], for dates of service [Start Date] to [End Date]. Purpose: [Insurance appeal, tax documentation, care coordination].

This authorization is effective on the date signed and expires on [Expiration Date]. I understand I may revoke this authorization at any time by sending a written request to your Health Information Management Department, except to the extent that action has already been taken in reliance upon it.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

Enclosures: Copy of patient photo ID; copy of spouse photo ID

4. Adult Child Authorization to Collect Records for Elderly Parent

[Parent Patient Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Adult Child to Pick Up Medical Records

Patient: [Parent’s Full Name]
Date of Birth: [MM/DD/YYYY]

I authorize my adult child, [Adult Child’s Full Name], to pick up and receive my medical records from [Facility or Provider Name]. The authorized individual will present photo identification at pickup.

Records requested: [Primary care notes, medication list, discharge summaries, imaging], for dates [Start Date] to [End Date]. Purpose: Care management and transition planning.

This authorization is valid through [Expiration Date] unless revoked in writing. I understand that once information is disclosed, it may be redisclosed by the recipient and may no longer be protected by HIPAA.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

If signed by personal representative, describe authority: __________________________

Enclosures: Copy of patient photo ID; copy of adult child photo ID

5. Authorization for Trusted Friend or Caregiver to Collect Records

[Patient Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Caregiver to Pick Up Medical Records

Patient: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]

I authorize [Caregiver or Friend Full Name], my [Relationship], to collect and receive my medical records from [Facility or Provider Name]. The authorized individual will present a valid photo ID.

Records requested: [Medication list, treatment plan, care instructions, therapy notes], for dates of service [Start Date] to [End Date]. Purpose: Home care coordination and follow up.

This authorization remains effective until [Expiration Date] and may be revoked at any time by written notice. I acknowledge that once disclosed, information may be subject to redisclosure.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

Enclosures: Copy of patient photo ID; copy of caregiver photo ID

6. Attorney or Legal Representative Authorization to Collect Records

[Client Patient Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Attorney to Obtain Medical Records

Patient: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]

I authorize my attorney, [Attorney Full Name], of [Law Firm Name], to obtain and pick up my medical records from [Facility or Provider Name]. The firm may designate staff or a courier to collect the records upon presentation of identification and this authorization.

Records requested: Complete chart including intake notes, progress notes, operative reports, imaging and radiology reports, pathology, laboratory results, billing ledger, and itemized statements for dates of service [Start Date] to [End Date]. Purpose: Legal evaluation and claim documentation.

This authorization is effective immediately and expires on [Expiration Date]. I understand I may revoke this authorization in writing at any time. Please disclose records even if they contain information regarding alcohol or drug treatment, mental health, or communicable diseases to the extent permitted by law.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

Enclosures: Copy of patient photo ID; attorney business card or letter of representation; copy of courier photo ID if applicable

7. Self Authorization for Courier Pickup or Electronic Delivery

[Patient Name]
[Address]
[City, State ZIP]
[Phone] | [Email]
Date: [Month Day, Year]

Health Information Management Department
[Facility or Provider Name]
[Address]
[City, State ZIP]

Subject: Authorization for Courier Pickup or Secure Electronic Release

Patient: [Full Legal Name]
Date of Birth: [MM/DD/YYYY]

I authorize [Courier or Service Name] and its agent [Agent Full Name] to pick up my medical records from [Facility or Provider Name] on my behalf. A copy of this authorization and government issued ID will be presented at pickup. You may alternatively provide a secure electronic copy to [Secure Email or Portal] or fax to [Secure Fax Number], attention [Recipient].

Records requested: [Specific record types], for dates [Start Date] to [End Date]. Purpose: Personal records retention and continuity of care.

This authorization expires on [Expiration Date] unless revoked earlier in writing. I acknowledge the possibility of redisclosure by the recipient. Please contact me at [Phone or Email] if fees apply or if additional consent is required.

Signature of Patient: _________________________ Date: __________
Printed Name: ________________________________

Enclosures: Copy of patient photo ID; courier authorization letter; courier photo ID