Healthcare Letter Attestation

Healthcare Letter Attestation

Patient Name:   Date of Birth:   Gender:

Contact & Insurance

Medical Background (Summary)

Letter Request Details

Attending Provider / Practice Name:

Period for which documentation is requested (from):   to:

Please indicate the specific content you authorize the provider to include in the attestation letter (check all that apply):

If mental health content is requested, I understand that psychotherapy notes require special authorization and are not released absent separate, specific consent. Initial to authorize mental health content:

Authorization & Attestation

By signing below I authorize the attending provider and its agents to prepare an attestation letter that may include the items I have selected above and to disclose the information described to the recipient named in this form. I understand that the letter may contain protected health information and that disclosure by the recipient may no longer be protected.

I attest that the information I have provided on this form is true and accurate to the best of my knowledge. I authorize release of medical information necessary to complete the attestation. I understand that falsifying information may be subject to applicable legal or administrative penalties.

Unless a different date is specified above, this authorization will expire one year from the date signed. I understand I may revoke this authorization at any time by providing a written notice, except to the extent that action has already been taken in reliance on this authorization.

Fees, Processing & Limits

I understand there may be reasonable fees for preparation of an attestation letter and for copying records. I authorize the provider to charge applicable fees and to withhold the letter until fees are paid, as permitted by law. Expedited preparation may be subject to additional charges.

HIPAA Acknowledgement

I acknowledge that I have been informed of my rights regarding my protected health information. This authorization is voluntary. I understand that I may refuse to sign this form and that refusal will not affect my ability to obtain treatment, payment, or enrollment in a health plan.

Additional Instructions or Restrictions

Certification

By signing below I certify that I am the patient or the patient's legally authorized representative. I understand the provider will rely on the information on this form in preparing the requested attestation. I release the provider and its employees from liability for disclosures made in good faith pursuant to this authorization.

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