Maricopa Arizona Sample Letter for Medical Authorization for Client Medical History

• Category: Letters - Legal - Workers Compensation
• State: Multi-State
• County: Maricopa
• 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] [Name of Medical Provider] [Medical Provider's Address] [City, State, ZIP] Subject: Authorization for Release of Medical Records Dear [Name of Medical Provider], I am writing to request the release of medical records for my client, [Client's Full Name]. As [Client's Name]'s healthcare provider, I understand the importance of having a comprehensive medical history to ensure the necessary medical care is provided effectively. 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] Email Address: [Client's Email Address] I hereby authorize the release of [Client's Name]'s complete medical and health records from [Medical Provider's Name]. These records may include, but are not limited to, medical history, laboratory results, diagnostic reports, radiology images, medication records, pathology reports, and surgical notes. The purpose of this request is to enable [Client's Name] to receive medical care from another healthcare provider. In order to ensure continuity of care and to avoid any potential complications, it is crucial that the receiving medical provider has a thorough understanding of [Client's Name]'s medical history. To facilitate the process, please provide the requested records in an electronic format, if available. If electronic records are not feasible, please provide them in hard copy format. To ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations, please provide these records within [reasonable time frame, e.g., 30 days] from the date of this authorization letter. In accordance with HIPAA guidelines, I understand that the medical provider may charge a reasonable fee for copying and mailing the records, which I am willing to pay. Please find attached a copy of [Client's Name]'s signed HIPAA Authorization form, which grants the necessary permission for the release of medical records. Additionally, if your office requires any additional documentation or forms to process this request, please do not hesitate to inform me. Should you have any questions or require further information, please feel free to contact me at [Your Phone Number] or via email at [Your Email Address]. Thank you for your prompt attention to this matter. Sincerely, [Your Name] [Your Title, if applicable]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Name of Medical Provider] [Medical Provider's Address] [City, State, ZIP] Subject: Authorization for Release of Medical Records Dear [Name of Medical Provider], I am writing to request the release of medical records for my client, [Client's Full Name]. As [Client's Name]'s healthcare provider, I understand the importance of having a comprehensive medical history to ensure the necessary medical care is provided effectively. 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] Email Address: [Client's Email Address] I hereby authorize the release of [Client's Name]'s complete medical and health records from [Medical Provider's Name]. These records may include, but are not limited to, medical history, laboratory results, diagnostic reports, radiology images, medication records, pathology reports, and surgical notes. The purpose of this request is to enable [Client's Name] to receive medical care from another healthcare provider. In order to ensure continuity of care and to avoid any potential complications, it is crucial that the receiving medical provider has a thorough understanding of [Client's Name]'s medical history. To facilitate the process, please provide the requested records in an electronic format, if available. If electronic records are not feasible, please provide them in hard copy format. To ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) regulations, please provide these records within [reasonable time frame, e.g., 30 days] from the date of this authorization letter. In accordance with HIPAA guidelines, I understand that the medical provider may charge a reasonable fee for copying and mailing the records, which I am willing to pay. Please find attached a copy of [Client's Name]'s signed HIPAA Authorization form, which grants the necessary permission for the release of medical records. Additionally, if your office requires any additional documentation or forms to process this request, please do not hesitate to inform me. Should you have any questions or require further information, please feel free to contact me at [Your Phone Number] or via email at [Your Email Address]. Thank you for your prompt attention to this matter. Sincerely, [Your Name] [Your Title, if applicable]