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] [Date] [Name of Medical Provider] [Address] [City, State, ZIP] Subject: Request for Release of Medical Records in Social Security Disability Action Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records in connection with my Social Security Disability Action. It is imperative that I obtain these records to support my disability claim accurately. I am a resident of Oakland, Michigan, and have been pursuing my Social Security Disability claim through the Social Security Administration (SSA). As per their requirements, I am required to provide comprehensive medical documentation to substantiate my disability and its impact on my daily functioning. Therefore, I hereby authorize the release of all relevant medical records and information related to my treatment, consultations, diagnostic tests, surgical procedures, and any other documentation pertinent to my disability evaluation. Please include all records from the past five years, or the maximum extent permissible by law. To ensure a smooth process, I have enclosed a copy of the SSA's Medical Records Release form, duly completed and signed. This form mandates compliance with all relevant HIPAA regulations and serves as my official consent for the release of medical records. Please note that this authorization is valid until my disability claim is resolved or until further notice from me. If there are any fees associated with retrieving and copying the records, kindly inform me in advance. I am ready to cover reasonable costs associated with this request. Additionally, I would appreciate it if you could provide the records in electronic format, as this would facilitate their submission and review by the SSA. If you have any questions or require further information regarding my request, please do not hesitate to contact me. The easiest way to reach me is via the phone number or email address provided below. Thank you for your prompt attention to this matter. Your cooperation is greatly appreciated, and I look forward to receiving the requested records as soon as possible. Your contribution will be instrumental in strengthening my disability claim and ensuring a fair evaluation by the Social Security Administration. Yours sincerely, [Your Name] [Your Contact Information]
[Your Name] [Your Address] [City, State, ZIP] [Date] [Name of Medical Provider] [Address] [City, State, ZIP] Subject: Request for Release of Medical Records in Social Security Disability Action Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request the release of my medical records in connection with my Social Security Disability Action. It is imperative that I obtain these records to support my disability claim accurately. I am a resident of Oakland, Michigan, and have been pursuing my Social Security Disability claim through the Social Security Administration (SSA). As per their requirements, I am required to provide comprehensive medical documentation to substantiate my disability and its impact on my daily functioning. Therefore, I hereby authorize the release of all relevant medical records and information related to my treatment, consultations, diagnostic tests, surgical procedures, and any other documentation pertinent to my disability evaluation. Please include all records from the past five years, or the maximum extent permissible by law. To ensure a smooth process, I have enclosed a copy of the SSA's Medical Records Release form, duly completed and signed. This form mandates compliance with all relevant HIPAA regulations and serves as my official consent for the release of medical records. Please note that this authorization is valid until my disability claim is resolved or until further notice from me. If there are any fees associated with retrieving and copying the records, kindly inform me in advance. I am ready to cover reasonable costs associated with this request. Additionally, I would appreciate it if you could provide the records in electronic format, as this would facilitate their submission and review by the SSA. If you have any questions or require further information regarding my request, please do not hesitate to contact me. The easiest way to reach me is via the phone number or email address provided below. Thank you for your prompt attention to this matter. Your cooperation is greatly appreciated, and I look forward to receiving the requested records as soon as possible. Your contribution will be instrumental in strengthening my disability claim and ensuring a fair evaluation by the Social Security Administration. Yours sincerely, [Your Name] [Your Contact Information]