Free Legal Forms
| Authorization to Release Medical Records, Cover Letter |
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Name Insurance Coverage In: Plan #: Family Name Covered Under Plan: Individual Covered & Subject to This Letter: Social Security Number of Individual: To: Medical Office Manager I am writing to request a copy of my medical records. Please send it to me at the address on this letterhead. I was formerly a patient of Dr. __________. Enclosed is a signed Authorization to Release Medical Records. I am requesting the records for insurance-related reasons. If there is a charge for copying the records, please submit a statement with the records and I will remit payment or charge it to my credit card number: ____________________ Expiration Date: _________; Under my name listed exactly as: __________________. Thank you for your continued good service that I have received in the past. Best regards, ____________ Writer Enclosure: Authorization to Release Medical Records Faxed and Mailed (Unless you can’t fax; if you cannot, then remove this notation). |
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