Sample Health Authorization Letter
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Mary Clark
111 Main St.
Los Angeles, CA 90034
January 12, 2013
Julie Davis
5432 Apple St.
Los Angeles, CA 90087
To whom it may concern,
I, Mary Clark, mother of Lily Clark, age 2, authorize Julie Davis to perform any acts that are
necessary to ensure the health of my child while I am away and she is under Julie’s care.
This includes any doctor/hospital visits, medicine, vaccines, or surgeries. Lily’s medical record
number is 12334556.
This authorization shall be valid between the dates of February 20, 2013 to March 1, 2013.
Thank you for your assistance in this matter.

Sincerely,

Mary Clark