1910.1020 App A - Sample authorization letter for the ...-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient’s Legal Name, Telephone, and Date of Birth in the designated fields.
3. Fill in the Address, City, State, and Zip code to ensure accurate delivery of your medical records.
4. Select how you would like to receive the information: Mailed, Picked-up, or Electronic Delivery. If choosing Electronic Delivery, be prepared to complete an additional form.
5. Indicate the purpose of your request by checking one or more boxes such as Personal, Treatment, or Healthcare Operations.
6. Specify which medical records you wish to obtain by checking the relevant boxes under 'Please furnish the following'.
7. Complete the date range for treatment by filling in 'From' and 'To' dates.
8. Sign and date at the bottom of the form to authorize release and ensure all information is correct before submission.

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