Letter and Authorization to Obtain Medical Records and Billing Information

for Your State
1 Review

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.

For Immediate Download

$7.99 Add to Cart
Free eSignature included
with every order
Please select a state

File types included

  • Microsoft Word
  • Adobe PDF
  • WordPerfect
  • Rich Text Format

Compatible with

  • Windows
  • Mac OS X
  • Linux

For Immediate Download

$7.99 Add to Cart
Free eSignature included
with every order
Please select a state

Attorney prepared

Our forms are kept up-to-date and accurate by our lawyers

Unlike other sites, every document on FindLegalForms.com is prepared by an attorney, so you can be sure that you are getting a form that is accurate and valid in your state.

Valid in your state

Our forms are guaranteed
to be valid in your state

Our team works tirelessly to keep our products current. As the laws change in your state, so do our forms.

Over 3,500,000
satisfied customers

In over 10 years of creating and selling legal forms, our focus has never changed: providing our customers high quality legal products, low prices and an experience that takes some confusion out of the law.

Free eSignature

Sign your form online, free with any form purchase

We now provide a free Electronic Signature Service to all of our visitors. There are no hidden charges or subscription fees, it's just plain free.

60-Days Money Back

Try our forms with no risk

If you are unhappy with your form purchase for any reason at all, contact us within 60 days and we will refund 100% of your money back.
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.
 
 Date                           
 
 
 
              
 
Attention     :  Medical Records/Billing Department
 
Regarding    :  Our Client          :    
Date of Loss       :   
      Date of Birth       :   
      SSN          :   
      Date of Service    :           
 
To whom it may concern:
 
This letter is to advise you that this law office has been retained by the above mentioned with reference to an injury sustained on ___________________.
 
Enclosed please find a fully executed HIPPA-compliant authorization for the release of any and all medical records and bills pertaining to the above-mentioned dates of service.  Please forward these records and bills to our office IMMEDIATELY.  
 
Thank you for your time and consideration in this matter.  Please feel free to contact the undersigned should you have any questions concerning this correspondence.
 
Very truly yours,
 
_____________________.
 
 
 
 
Enclosure
 
MEDICAL RECORDS AND BILLING
INFORMATION RELEASE AUTHORIZATION
 
The below described patient hereby authorizes XXX, Attorneys, to obtain, pursuant to HIPAA Rule (Section 164.508), the following information or documents upon the below described terms.
 
1.   The medical provider is authorized to provide any information requested, including all reports, notes, electronic data, lab tests, x-rays, medical imaging, billing information, or any other documents; also, the below described provider is authorized to provide written or oral reports as requested by XXX, Attorneys for the last five (5) years before the accident of _______________.
 
2.   The entity to whom this authorization is directed to is:______________________
 
3.   The above entity can make disclosure of medical information or billing information to XXX, Attorneys. or any employee or agent of said law firm.  This does not allow these lawyers to speak with the treating medical providers.
 
4.   The purpose of this disclosure is to obtain information for use by my attorneys in connection with a legal claim or proceeding.  The expiration date of this authorization is two (2) years from the date of the signature below.
 
5.   The undersigned understands that he or she may revoke this authorization at any time, without exceptions, by sending a written request to XXX, Attorneys and/or to the medical provider.
 
6.   The undersigned understands that the information obtained by XXX, Attorneys pursuant to this authorization may be used by them for purposes of any legal claims being presented by XXX, Attorneys on behalf of the below described individual.  The undersigned understands that if medical records are obtained by XXX, Attorneys, that said records or copies may be provided to those entities, or their representatives, against whom legal claims are being presented; and said records will be subject to examination by XXX, Attorneys and those employees or agents hired by XXX, Attorneys to examine said documents for purposes of legal claims or proceedings.  If said information is provided to insurance adjusters, defense lawyers, or others against whom the legal proceeding or claim is presented, said disclosure will not be subject to the HIPAA Rule.
 
7.   I may revoke this authorization at any time in writing, but if I do, it will not have any affect on my actions taken prior to receiving the revocation.  Further details may be found in the Notice of Privacy Practices.
 
8.   I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
 
DATED this _____ day of ____________________, 20______.                                            
_________________________________________
Client/Patient
 
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.
 
 Date                           
 
 
 
              
 
Attention     :  Medical Records/Billing Department
 
Regarding    :  Our Client          :    
Date of Loss       :   
      Date of Birth       :   
      SSN          :   
      Date of Service    :           
 
To whom it may concern:
 
This letter is to advise you that this law office has been retained by the above mentioned with reference to an injury sustained on ___________________.
 
Enclosed please find a fully executed HIPPA-compliant authorization for the release of any and all medical records and bills pertaining to the above-mentioned dates of service.  Please forward these records and bills to our office IMMEDIATELY.  
 
Thank you for your time and consideration in this matter.  Please feel free to contact the undersigned should you have any questions concerning this correspondence.
 
Very truly yours,
 
_____________________.
 
 
 
 
Enclosure
 
MEDICAL RECORDS AND BILLING
INFORMATION RELEASE AUTHORIZATION
 
The below described patient hereby authorizes XXX, Attorneys, to obtain, pursuant to HIPAA Rule (Section 164.508), the following information or documents upon the below described terms.
 
1.   The medical provider is authorized to provide any information requested, including all reports, notes, electronic data, lab tests, x-rays, medical imaging, billing information, or any other documents; also, the below described provider is authorized to provide written or oral reports as requested by XXX, Attorneys for the last five (5) years before the accident of _______________.
 
2.   The entity to whom this authorization is directed to is:______________________
 
3.   The above entity can make disclosure of medical information or billing information to XXX, Attorneys. or any employee or agent of said law firm.  This does not allow these lawyers to speak with the treating medical providers.
 
4.   The purpose of this disclosure is to obtain information for use by my attorneys in connection with a legal claim or proceeding.  The expiration date of this authorization is two (2) years from the date of the signature below.
 
5.   The undersigned understands that he or she may revoke this authorization at any time, without exceptions, by sending a written request to XXX, Attorneys and/or to the medical provider.
 
6.   The undersigned understands that the information obtained by XXX, Attorneys pursuant to this authorization may be used by them for purposes of any legal claims being presented by XXX, Attorneys on behalf of the below described individual.  The undersigned understands that if medical records are obtained by XXX, Attorneys, that said records or copies may be provided to those entities, or their representatives, against whom legal claims are being presented; and said records will be subject to examination by XXX, Attorneys and those employees or agents hired by XXX, Attorneys to examine said documents for purposes of legal claims or proceedings.  If said information is provided to insurance adjusters, defense lawyers, or others against whom the legal proceeding or claim is presented, said disclosure will not be subject to the HIPAA Rule.
 
7.   I may revoke this authorization at any time in writing, but if I do, it will not have any affect on my actions taken prior to receiving the revocation.  Further details may be found in the Notice of Privacy Practices.
 
8.   I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
 
DATED this _____ day of ____________________, 20______.                                            
_________________________________________
Client/Patient
 
You've found your form, but will you need others? If there are other related forms you may need in the future, it may be beneficial to look at our combo packages. On average, customers who purchase a combo package save 40% on the related forms they need. Take a look at the combo packages below to see if one is right for you.
Attorney Letters Combo Package Get 10 forms for just $14.95 Save 68%! Popular Save Money with this combo package containing all of our letters used by attorneys

Customer Reviews

Average Rating: Full Rating Star Full Rating Star Full Rating Star Full Rating Star Full Rating Star

Reviews: 1


Attica,

OH

Full Rating Star Full Rating Star Full Rating Star Full Rating Star Full Rating Star
No Customer Comments


Looking for something else?