Authorization Letter Sample

This Authorization Letter sample is available for use on UpCounsel. Download this free sample authorization letter below and have it customized for your unique business legal needs today.


I, ____________, (full name) hereby authorize __________ (individual or organization holding the pertinent records) to release to _________ (individual or organization authorized to receive the pertinent information), the following [type of information:  medical, financial, legal] information from my personal records:

Describe generally the information desired to be released).

I give my permission for this [
medical/financial/legal information] to be used for
the following purpose:

but I do not give permission for any other use or re-disclosure of this information. I also do not give permission for any other portions of my [
medical/financial/legal] information to be released as a result of this letter.

This letter expires on the _____ day of ___________, 20___.

Full name of Employee or Legal Representative


Signature of Employee or Legal Representative


Date of Signatures: _____________________________

Any [GREEN] highlighted language is intended to be filled in by the user. Any [YELLOW] highlighted language is considered optional or conditional by the attorney community. Consult with an attorney before using this document. This document is not a substitute for legal advice or services. Refer to our Terms of Use for more details.

This form has been prepared for general informational purposes only. It does not constitute legal advice, advertising, a solicitation, or tax advice. Transmission of this form and the information contained herein is not intended to create, and receipt thereof does not constitute formation of, an attorney-client relationship. You should not rely upon this document or information for any purpose without seeking legal advice from an appropriately licensed attorney, including without limitation to review and provide advice on the terms of this form, the appropriate approvals required in connection with the transactions contemplated by this form, and any securities law and other legal issues contemplated by this form or the transactions contemplated by this form.

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