[Date]

Dear [Name of doctor]:


I am generally familiar with the current Lyme disease controversy involving efforts of some government agencies to interfere

in an individual doctor's treatment decisions. I am also familiar with the controversy surrounding the diagnosis and

treatment of Lyme and other tick-borne disorders. You and I have fully discussed the risks and benefits of the course of

action that we have taken to my diagnosis and care plan and we have both agreed to that course of action.  I also want to let

you know that I specifically instruct that you are not authorized to release any of my medical records in your possession to

any government agency or medical licensing board or to any person representing or acting on behalf of these groups.  If you

receive any request or demand for my medical records from any of these groups, please let me know promptly.

Also, will you please place this letter in my medical records file.


Sincerely,


[Patient]