San Bernardino California Sample Letter for Enclosure of Medical Reports

• Category: Letters - Legal - Workers Compensation
• State: Multi-State
• County: San Bernardino
• Control #: US-0950LTR
• Format: Word; Rich Text

Description

This form is a sample letter in Word format covering the subject matter of the title of the form. Subject: Request for Enclosure of Medical Reports — [Patient Name] [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Designation] [Hospital/Clinic Name] [Address] [City, State, ZIP Code] Dear [Recipient's Name], I hope this letter finds you in good health. I am writing to kindly request the enclosure of medical reports for [Patient Name], whom I represent as [relationship to the patient, e.g., legal guardian, spouse, etc.]. The provided medical reports are essential for our ongoing legal proceedings/insurance claim/patient's medical history (select one). As per our conversation on [mention date or any reference], it is imperative for us to gather comprehensive medical documentation relating to [Patient Name]'s health status as it pertains to [describe the purpose or context, e.g., our upcoming court hearing, insurance claim evaluation, etc.]. Enclosed you will find a copy of the required authorization form signed by [Patient Name], granting permission to access and share their medical records. To facilitate the process, I kindly request you to compile the following medical reports and enclose them in the provided self-addressed envelope(s): 1. Complete medical history records, including but not limited to: — Admission and dischargsummariesie— - Emergency room reports — Diagnosis and treatment record— - Laboratory test results — Radiology/imaging report— - Surgical/procedural notes — Progress note— - Consultation reports from specialists 2. Any available pathology reports, biopsy results, or histopathology assessments. 3. Current medication records, including prescribed medications, dosages, and any related adverse effects or drug interactions. 4. Imaging studies such as X-rays, MRIs, CT scans, ultrasounds, etc., along with their respective interpretations. 5. Mental health records, if applicable, including psychological assessments, therapy notes, and psychiatric evaluations. In addition to the above, kindly enclose any other relevant medical reports or documents that might provide a comprehensive overview of [Patient Name]'s medical condition. It is crucial to ensure that all enclosed documentation is current and up to date, ideally including reports from the past [mention time period, e.g., five years]. As time is of the essence, and to avoid any delays or inconveniences, I kindly request you to process and send the enclosed medical reports to the following address: [Your Address] [City, State, ZIP Code] To cover any associated costs, please let me know if any fees or charges apply for this service. I am more than willing to provide the necessary payment promptly. I genuinely appreciate your kind attention and assistance in this matter. If you have any queries or require further information, please do not hesitate to contact me at [your contact number] or [email address]. Thank you for your cooperation, and I am looking forward to receiving the requested medical reports at your earliest convenience. Sincerely, [Your Name] Enclosure: — Signed Authorization For— - Self-addressed envelope(s)

Subject: Request for Enclosure of Medical Reports — [Patient Name] [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Designation] [Hospital/Clinic Name] [Address] [City, State, ZIP Code] Dear [Recipient's Name], I hope this letter finds you in good health. I am writing to kindly request the enclosure of medical reports for [Patient Name], whom I represent as [relationship to the patient, e.g., legal guardian, spouse, etc.]. The provided medical reports are essential for our ongoing legal proceedings/insurance claim/patient's medical history (select one). As per our conversation on [mention date or any reference], it is imperative for us to gather comprehensive medical documentation relating to [Patient Name]'s health status as it pertains to [describe the purpose or context, e.g., our upcoming court hearing, insurance claim evaluation, etc.]. Enclosed you will find a copy of the required authorization form signed by [Patient Name], granting permission to access and share their medical records. To facilitate the process, I kindly request you to compile the following medical reports and enclose them in the provided self-addressed envelope(s): 1. Complete medical history records, including but not limited to: — Admission and dischargsummariesie— - Emergency room reports — Diagnosis and treatment record— - Laboratory test results — Radiology/imaging report— - Surgical/procedural notes — Progress note— - Consultation reports from specialists 2. Any available pathology reports, biopsy results, or histopathology assessments. 3. Current medication records, including prescribed medications, dosages, and any related adverse effects or drug interactions. 4. Imaging studies such as X-rays, MRIs, CT scans, ultrasounds, etc., along with their respective interpretations. 5. Mental health records, if applicable, including psychological assessments, therapy notes, and psychiatric evaluations. In addition to the above, kindly enclose any other relevant medical reports or documents that might provide a comprehensive overview of [Patient Name]'s medical condition. It is crucial to ensure that all enclosed documentation is current and up to date, ideally including reports from the past [mention time period, e.g., five years]. As time is of the essence, and to avoid any delays or inconveniences, I kindly request you to process and send the enclosed medical reports to the following address: [Your Address] [City, State, ZIP Code] To cover any associated costs, please let me know if any fees or charges apply for this service. I am more than willing to provide the necessary payment promptly. I genuinely appreciate your kind attention and assistance in this matter. If you have any queries or require further information, please do not hesitate to contact me at [your contact number] or [email address]. Thank you for your cooperation, and I am looking forward to receiving the requested medical reports at your earliest convenience. Sincerely, [Your Name] Enclosure: — Signed Authorization For— - Self-addressed envelope(s)