Houston Texas Sample Letter for Medical Authorization for Client Medical History

• Category: Letters - Legal - Workers Compensation
• State: Multi-State
• City: Houston
• 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] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Address] [City, State, ZIP] Subject: Medical Authorization for Client's Medical History Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request your cooperation in providing us with the medical history of our client, [Client's Full Name], as part of their ongoing medical treatment. As the authorized representative, I hereby grant permission for the release of their medical records for the purposes of compassionate and effective care. Client Information: — Full Name: [Client's Full Name— - Date of Birth: [Client's Date of Birth] — Address: [Client's Address— - Contact Number: [Client's Contact Number] — Health Insurance: [Client's Insurance Provider] We kindly request you to release and provide copies of all relevant medical records, including but not limited to the following: 1. Personal Information: — Identification documents (e.g., driver's license, passport) — Emergency contact detail— - Address history 2. Medical History: — Previous diagnose— - Surgical procedures — Medical conditions and treatment— - Allergies and sensitivities — Medication history, including active prescriptions — Results of laboratory tests and diagnostic imaging — Mental health records (if applicable— - Substance abuse treatment records (if applicable) 3. Specialist Consultations: — Reports and notes from previous consultations with specialists — Referral letters and recommendations for further treatment 4. Hospitalization and Emergency Room Visits: — Admission record— - Discharge summaries — Operative notes (if applicable) 5. Therapeutic and Rehabilitation Services: — Physical therapy report— - Occupational therapy reports — Speech therapy report— - Rehabilitation progress notes 6. Immunization Records: — Vaccination history and records Please note that this authorization is valid for the period [Start Date] to [End Date], after which it will expire. In accordance with legal guidelines, we understand that any disclosed information will be used solely for the purpose of providing appropriate care to the client. I kindly request that you provide the requested information at your earliest convenience. If there are any fees or charges associated with obtaining the medical records, please inform me beforehand. I can be reached via email or phone. We greatly appreciate your prompt attention to this matter. Thank you for your cooperation and assistance in ensuring the best possible medical care for our client. Your support in this endeavor is invaluable. Yours sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Recipient's Name] [Recipient's Address] [City, State, ZIP] Subject: Medical Authorization for Client's Medical History Dear [Recipient's Name], I hope this letter finds you in good health and high spirits. I am writing to request your cooperation in providing us with the medical history of our client, [Client's Full Name], as part of their ongoing medical treatment. As the authorized representative, I hereby grant permission for the release of their medical records for the purposes of compassionate and effective care. Client Information: — Full Name: [Client's Full Name— - Date of Birth: [Client's Date of Birth] — Address: [Client's Address— - Contact Number: [Client's Contact Number] — Health Insurance: [Client's Insurance Provider] We kindly request you to release and provide copies of all relevant medical records, including but not limited to the following: 1. Personal Information: — Identification documents (e.g., driver's license, passport) — Emergency contact detail— - Address history 2. Medical History: — Previous diagnose— - Surgical procedures — Medical conditions and treatment— - Allergies and sensitivities — Medication history, including active prescriptions — Results of laboratory tests and diagnostic imaging — Mental health records (if applicable— - Substance abuse treatment records (if applicable) 3. Specialist Consultations: — Reports and notes from previous consultations with specialists — Referral letters and recommendations for further treatment 4. Hospitalization and Emergency Room Visits: — Admission record— - Discharge summaries — Operative notes (if applicable) 5. Therapeutic and Rehabilitation Services: — Physical therapy report— - Occupational therapy reports — Speech therapy report— - Rehabilitation progress notes 6. Immunization Records: — Vaccination history and records Please note that this authorization is valid for the period [Start Date] to [End Date], after which it will expire. In accordance with legal guidelines, we understand that any disclosed information will be used solely for the purpose of providing appropriate care to the client. I kindly request that you provide the requested information at your earliest convenience. If there are any fees or charges associated with obtaining the medical records, please inform me beforehand. I can be reached via email or phone. We greatly appreciate your prompt attention to this matter. Thank you for your cooperation and assistance in ensuring the best possible medical care for our client. Your support in this endeavor is invaluable. Yours sincerely, [Your Name]