South Dakota Sample Letter for Medical Authorization for Client Medical History

• Category: Letters - Legal - Workers Compensation
• State: Multi-State
• Control #: US-0951LTR
• 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] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Address] [City, State, Zip Code] Subject: Authorization for Release of Medical Records Dear [Recipient's Name], I am writing to request your assistance in obtaining the medical history of my client, [Client's Full Name], in relation to their healthcare services in South Dakota. As their authorized representative, I seek permission to access and receive copies of their medical records for the purpose of [state the specific reason, e.g., reviewing the medical history, coordinating their care, etc.]. I would like to provide you with relevant information regarding the client, which will help you locate and gather their medical records efficiently: Client's Full Name: [Client's Full Name] Date of Birth: [Client's Date of Birth] Social Security Number: [Client's SSN, if applicable] Health Insurance Information: [Client's Insurance Provider and Policy Number, if available] Dates of Service: [Specify the specific time period or dates when medical services were provided, if known] In compliance with the federal and state laws pertaining to the privacy and confidentiality of medical information, including the Health Insurance Portability and Accountability Act (HIPAA), I am enclosing a signed copy of the written authorization from the client, granting me permission to access their medical records. This authorization is valid for one year from the date of signing. Please find attached: 1. Authorization for Release of Medical Records signed by the client (or Power of Attorney if applicable). 2. Copy of my identification (e.g., driver's license, passport) as the client's authorized representative. 3. Any additional documents required by your facility for processing this request. Kindly note that it is essential to ensure the accuracy and completeness of the collected medical records. If there are any costs associated with retrieving and copying the documents, please inform me beforehand. I will be responsible for any reasonable fees incurred. Please send the requested medical records to the following address: [Your Address] [City, State, Zip Code] If you require further information or have any questions or concerns regarding this request, please do not hesitate to contact me at [Phone Number] or via email at [Email Address]. I appreciate your prompt attention to this matter. Thank you for your cooperation and assistance in helping us access the required medical information on behalf of our client. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, Zip Code] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Address] [City, State, Zip Code] Subject: Authorization for Release of Medical Records Dear [Recipient's Name], I am writing to request your assistance in obtaining the medical history of my client, [Client's Full Name], in relation to their healthcare services in South Dakota. As their authorized representative, I seek permission to access and receive copies of their medical records for the purpose of [state the specific reason, e.g., reviewing the medical history, coordinating their care, etc.]. I would like to provide you with relevant information regarding the client, which will help you locate and gather their medical records efficiently: Client's Full Name: [Client's Full Name] Date of Birth: [Client's Date of Birth] Social Security Number: [Client's SSN, if applicable] Health Insurance Information: [Client's Insurance Provider and Policy Number, if available] Dates of Service: [Specify the specific time period or dates when medical services were provided, if known] In compliance with the federal and state laws pertaining to the privacy and confidentiality of medical information, including the Health Insurance Portability and Accountability Act (HIPAA), I am enclosing a signed copy of the written authorization from the client, granting me permission to access their medical records. This authorization is valid for one year from the date of signing. Please find attached: 1. Authorization for Release of Medical Records signed by the client (or Power of Attorney if applicable). 2. Copy of my identification (e.g., driver's license, passport) as the client's authorized representative. 3. Any additional documents required by your facility for processing this request. Kindly note that it is essential to ensure the accuracy and completeness of the collected medical records. If there are any costs associated with retrieving and copying the documents, please inform me beforehand. I will be responsible for any reasonable fees incurred. Please send the requested medical records to the following address: [Your Address] [City, State, Zip Code] If you require further information or have any questions or concerns regarding this request, please do not hesitate to contact me at [Phone Number] or via email at [Email Address]. I appreciate your prompt attention to this matter. Thank you for your cooperation and assistance in helping us access the required medical information on behalf of our client. Sincerely, [Your Name]