Free Medical Report Request Template
Medical Report Request
TO: Multinumeris
ADDRESS: Tacoma, WA 98401
PHONE NUMBER: 222 555 7777
FAX NUMBER: 222 555 7777
FROM: [Your Name], [Your Company Name]
ADDRESS: [Your Company Address]
PHONE NUMBER: [Your Company Number]
DATE OF REQUEST: March 1, 2089
PATIENT INFORMATION
|
FIELD |
DETAIL |
|---|---|
|
Patient Full Name: |
Sophie Fadel |
|
Date of Birth: |
January 15, 2065 |
|
Patient ID/SSN: |
987-65-4321 |
|
Contact Number: |
222 555 7777 |
|
Address: |
Tacoma, WA 98401 |
DETAILS OF REQUEST
Purpose of Request: For insurance claim review and continuity of care.
Specific Records Requested: Please provide the following:
-
Complete medical history for the period January 2080 – December 2088
-
Lab results for routine bloodwork and specific tests conducted on March 10, 2088
-
Imaging reports, including X-rays and MRIs conducted between June 2085 and November 2088
Preferred Format of Records: Electronic format (PDF or other secure format preferred).
Deadline for Submission: March 15, 2089
AUTHORIZATION
Please find the attached signed release form from Sophie Fadel authorizing the release of the requested medical records.
NOTE: Should there be any associated costs for the processing of this request, kindly notify us beforehand.
Thank you for your prompt attention to this matter. If you have any questions or require further details, please contact me at [Your Email].
