Sample Letter of Consent to Release Medical Information

Sometimes medical or health situation warrants getting one’s medical report from another hospital or doctor if one is incapacitated. But the truth is that hospitals or medical providers do not ordinarily share this kind of information with any other person without a formal notice. So the best bet will be to write a letter of consent to release of your medical information. This is a very confidential information to the hospital so they do all they can to protect it.

So a letter of consent to release medical information is an authorization letter from the writer (a patient) to a hospital or medical provider for the release of his or her past medical report. This letter is to show the reader or recipient that the patient has authorized such action. The letter will enable the recipient to know the realness of the letter and for what reasons the information are demanded. The letter of consent to release medical information would give the vital information about the writer and help in expediting action of releasing the information.

Also Read:  Sample Permission Letter for Medical Treatment of a Child

Sample letter of consent to release medical information is a formal letter but a polite tone must be employed. This is a letter asking for a favor as such one needs to be courteous in the letter. To make the letter as efficient as it should be, the right information must be stated in the letter. 

Basic Outline of a Consent to Release Patient Information

  • Date your letter.
  • Address the hospital you would sending the letter and add their phone number.
  • Have a subject line for your letter.
  • Then add a formal salutation.
  • Next, is to introduce yourself and reason why you are writing the letter.
  • Provide your information, that will enable easy trace of your letter: information like your name, birth, phone no, hospital date of admission, last discharge date, the health information to be released.
  • Conclude by acknowledging that you are the one actually needing the report.
  • State the duration that the authorization will be in force.
  • Attach a self attested copy of you for better verification.
  • Conclude your letter and sign off.

Below are the Sample letters of consent to release medical information

Sample 1

12th August 2009

Blue-bird medical center

5467 hencoops street, Los Angeles


Sub: Authorizations for the release of my medical and health information

Dear Dr. Leo

I have been a patient of your hospital for 10 years now. I’m undergoing a medical treatment in another city far away from California. I came here for a business transaction, before I became ill and hospitalized. As at yesterday, the doctor handling my case requested for my medical history on my hypertension situation so far from my past hospital. So since I can’t possible make it to the clinic because of my ill-health .i will asked that you release my documents for medical reports to the bearer of this letter. For ease of tracing my medical document, I will state my personal data below:

Name: Princewill Morgan

Date of birth: 12th may 1980

Address: 4356 plink street, Los Angeles

Date of admission: 10th July 2021

Last Discharge: 14th Sept 2021

Health Information to be Released: My Hypertension Reports to Date

So on this note, I therefore request that you release these reports to the bearer of this letter, Lawrence Morgan my son to be given to the doctors here in Douglas life saving clinic. I do understand that these documents are really confidential documents but I can assure you that you would not be held liable if anything goes wrong in future. I promise to take full responsibility of this. This authorization will only be valid still 30th of Nov but I still reserve the right to revoke at any given time.

I enclose with this letter a self attested copy of my identity and a proof if my residential address for your perusal. Please kindly do the needful as I look forward to getting a positive feedback from you.

Yours sincerely,

Princewill Morgan

Sample 2

12th Sept, 2009


Bright star hospital

6789 Radian Street, Austin


Subject line: Request for the release of my medical information

Dear Sir,

I’m Mercy Emma, was a patient last year in your health facility. I’m undergoing a health treatment in Berry clinic Austin. My doctor is requesting to have a look at my past medical history concerning the evacuation I did in your hospital last year as I have developed some complications.

Though I was handed some of the documents but I seem not to be able to trace them now. So please be kind enough to release my copies once again to me. My medical data are as follows:

Name: Mercy Emma

Date of birth: 12th Nov, 1987

Phone: 657-987-123

Admitted to hospital: 12th April 2021

Last day of discharge: 10th May 2021

Health information needed: Reports that only concerns the evacuation that was carried out on the above admitted date.

With this, I hereby asked that your hospital release this information to my doctor here in Berry clinic. I know that these information are personally protected medical information, so I agree to be held liable for anything in future. I will take full responsibility for any issues arising from this action. This authorization will be enforce from now still when I revoke it.

For ease of verification and release of this information, I have attached with this letter one source of identification which is my official id card. Please go ahead with the release. Thanks for your understanding.

Yours sincerely,

Mercy Emma


Medical information isn’t for public consumption but there’s exception to all rules. If one’s medical report is needed by another medical provider or hospital, then the way out is to authorize the previous hospital to do the release. This will need you writing a letter of consent to release medical information. This will aid in quick release when verification has been done. You can use the guidelines above and the samples given to craft your letter of consent to release medical information to perfection.


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