Mississippi Sample Letter for Medical Records Release in Social Security Disability Action

• Category: Letters - Legal - Social Security
• State: Multi-State
• Control #: US-0959LTR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form. [Your Name] [Your Address] [City, State, Zip Code] [Phone Number] [Email Address] [Date] [Social Security Office Address] [City, State, Zip Code] Subject: Request for Release of Medical Records in Social Security Disability Action — [Your Name], [Social Security Number] Dear Sir/Madam, I am writing to formally request the release of my medical records in relation to my Social Security Disability Action. As per the regulations set forth by the Social Security Administration (SSA), I understand that it is my responsibility to provide all medical evidence relevant to my disability claim. To facilitate the efficient processing of my Social Security Disability claim, I kindly request that you release my medical records directly to the SSA by completing the attached Mississippi Sample Letter for Medical Records Release. By using this specific form, it ensures compliance with state and federal laws governing the release of medical records. Please find an outline of my relevant medical information below: 1. Claimant Information: — Name: [Your Full Name— - Social Security Number: [Your SSN] — Address: [Your Full Address— - Phone Number: [Your Phone Number] — Email Address: [Your Email Address] 2. Treating Healthcare Provider Details: — Name of Provider: [Provider's Full Name] — Address: [Provider's Full Address— - Phone Number: [Provider's Phone Number] — Fax Number: [Provider's Fax Number— - Email Address: [Provider's Email Address] — Medical Specialty: [Provider's Specialty] 3. Authorization Details: — Duration: This authorization shall remain in effect until my Social Security Disability claim is concluded, or until [specific date if applicable]. — Purpose: The purpose of this authorization is to release my medical records for evaluation in relation to my Social Security Disability claim. — Types of Medical Records: Please release all relevant medical records, including but not limited to, medical history, clinical notes, laboratory results, diagnostic images, treatment plans, and any other documents deemed necessary for the review of my disability claim. — Parties Authorized to Release the Records: The authorization is granted to the treating healthcare provider mentioned above. Once completed, please forward the signed and dated Mississippi Sample Letter for Medical Records Release to the Social Security Administration at the address provided in the form. Additionally, you may retain a copy for your records. I would greatly appreciate your immediate attention to this matter, as my Social Security Disability claim depends on the timely submission of medical evidence. Should you have any questions or require further information, please do not hesitate to contact me at your earliest convenience. Thank you in advance for your cooperation and assistance. Sincerely, [Your Full Name]

[Your Name] [Your Address] [City, State, Zip Code] [Phone Number] [Email Address] [Date] [Social Security Office Address] [City, State, Zip Code] Subject: Request for Release of Medical Records in Social Security Disability Action — [Your Name], [Social Security Number] Dear Sir/Madam, I am writing to formally request the release of my medical records in relation to my Social Security Disability Action. As per the regulations set forth by the Social Security Administration (SSA), I understand that it is my responsibility to provide all medical evidence relevant to my disability claim. To facilitate the efficient processing of my Social Security Disability claim, I kindly request that you release my medical records directly to the SSA by completing the attached Mississippi Sample Letter for Medical Records Release. By using this specific form, it ensures compliance with state and federal laws governing the release of medical records. Please find an outline of my relevant medical information below: 1. Claimant Information: — Name: [Your Full Name— - Social Security Number: [Your SSN] — Address: [Your Full Address— - Phone Number: [Your Phone Number] — Email Address: [Your Email Address] 2. Treating Healthcare Provider Details: — Name of Provider: [Provider's Full Name] — Address: [Provider's Full Address— - Phone Number: [Provider's Phone Number] — Fax Number: [Provider's Fax Number— - Email Address: [Provider's Email Address] — Medical Specialty: [Provider's Specialty] 3. Authorization Details: — Duration: This authorization shall remain in effect until my Social Security Disability claim is concluded, or until [specific date if applicable]. — Purpose: The purpose of this authorization is to release my medical records for evaluation in relation to my Social Security Disability claim. — Types of Medical Records: Please release all relevant medical records, including but not limited to, medical history, clinical notes, laboratory results, diagnostic images, treatment plans, and any other documents deemed necessary for the review of my disability claim. — Parties Authorized to Release the Records: The authorization is granted to the treating healthcare provider mentioned above. Once completed, please forward the signed and dated Mississippi Sample Letter for Medical Records Release to the Social Security Administration at the address provided in the form. Additionally, you may retain a copy for your records. I would greatly appreciate your immediate attention to this matter, as my Social Security Disability claim depends on the timely submission of medical evidence. Should you have any questions or require further information, please do not hesitate to contact me at your earliest convenience. Thank you in advance for your cooperation and assistance. Sincerely, [Your Full Name]