123 Main St., Apt. #5 Anytown, CA 95928 (555) 555-1212 firstname.lastname@example.org
November 8, 2008
Anytown Medical Center 345 Goodhealth Place Anytown, CA 95928
Dear Dr. Goodcare:
I am writing to authorize you to release my medical records to the office of Dr. Nice. He has expressed a desire to see my files to gain a more complete picture of my ongoing digestive problems.
Please send the files at your earliest convenience to: 134 Nice Way, Anytown, CA 95928.