YOUR COMPANY LETTERHEAD

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Date:

To Whom It May Concern:

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This letter is to authorize Shield Data Network, LLC to facilitate the release of medical information on behalf of      name of your agency     . These documents are required for legal purposes (or state other reason).

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     Name of your agency      and Shield Data Network, LLC are aware of the confidential nature of the personal health information being requested. The records being sought are for the sole purpose of the companies listed in this authorization.

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This authorization shall remain in effect until further notice.

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Please send records to:

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Shield Data Network, LLC
Attention: Records Department
Fax #: (919) 321-1195

or

Mail to:
Shield Data Network, LLC
Records Department
P.O. BOX 12798
65 TW Alexander Drive
Durham, NC 27709

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Sincerely,

[YOUR NAME]
[YOUR TITLE]