Sample Release of Information Letter

As a company, if you change contact information and need to update your clients, you can use this new contact information letter to tell them about your new address.

[Reciever’s Name], 

[Reciever’s Address], 

[City, State, ZIP], 


[Subject: Mention Release of Information in bold formatting] 

Dear [Reciever’s Name], 

I, [Mention Your Full Name], of age [Mention your Age], my social security address is [Mention Your Social Security Number], and my Medical Record Number is [Mention Your Medical Record Number]. I am currently living at [Mention Address. Include City, State, ZIP, and Country]. Let this letter be my authorization to release the below-mentioned documents to [Full Name of The Person You want to release the information to], residing at [Mention Their Full Address]. 

The records which I request you to release include the following: 

[Mention All The Records you want to be released]. 

The information being released upon my request shall only be limited to the purposes of: 

[Mention all the purposes for which you are getting the information released]. 

My authorization for the released documents shall remain effective till [Mention Last Date]. During this time, the Mentioned person will access my information, provided that they comply with the applicable laws. Furthermore, they must also take all administrative and technical measures to protect and secure the released information. 

Your attention to this matter is appreciated. 


[Sender’s Name].

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