To,

Medical Superintendent/ MRD officer,

<Name of the Hospital>
<Address>
Subject- Authorization for release of my medical/ health related documents
Dear Sir/ Madam,
I was a patient earlier being treated in your hospital. In order to get the reimbursement of medical expenses
incurred during my hospitalization, I have raised a claim under the health insurance policy held by me with
Navi General Insurance Company.
I hereby authorize your hospital to release the copies of my medical records to Navi General Insurance
company or to any person/ institution authorized by Navi General Insurance.
In order to release the records quickly, I am providing herewith the following information for your ready
reference.

Name: Date of Birth:

Address:

Phone No. Email id:

Date of Date of
Admission: Discharge:
Treating Doctor Doctor’s
Name Mobile No.
Patient’s Example: Salaried /
Employer or Teacher / Lawyer / CA /
Business Agent / Plumber /
Address Nature of Job Carpenter / Retailer etc.
I am enclosing herewith a self-attested copy of my identity and address proof for your verification purposes.
Kindly do the needful and oblige. Thanking you.
Yours Sincerely,

(Signature)
(Full name of the patient)
Date: