Letter and Authorization to Obtain Medical Records and Billing Information

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This Letter and Authorization to Obtain Medical Records and Billing allows an attorney access to a client's medical and billing information. An Information Release Authorization is also included with this letter and must be signed by your client.

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This Letter and Authorization to Obtain Medical Records and Billing will effectively request a client's medical records and information about the client's billings. This letter contains the name of the client, his or her date of birth, Social Security number and the date the request was sent. Also enclosed with the letter is an Information Release Authorization previously signed by the client authorizing disclosure of the records. A written Letter and Authorization to Obtain Medical Records and Billing will ensure that you receive the necessary information in order to move your client's case forward.

This Letter and Authorization to Obtain Medical Records and Billing includes the following:
  • Client Information: Sets forth the relevant information regarding the client, including full name and date of birth;
  • Representation: Informs the provider that your office was retained to represent the client regarding a specific injury (such as automobile or on the job accident);
  • Authorization: Encloses an Information Release Authorization signed by the client to ensure that the medical records are released.

Protect your rights by using our attorney-prepared forms.

This attorney-prepared packet contains:
  1. General Information
  2. Letter and Authorization to Obtain Medical Records and Billing
State Law Compliance: This form complies with the laws of all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
Number of Pages3
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28073
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
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