Healthcare Verification Letter

HEALTHCARE VERIFICATION LETTER

To:   Date:

Facility / Provider

Patient Information

Patient Name:   Date of Birth:

Insurance Information

Verification Requested

Please provide verification of the following (select all that apply):

Dates of service
Diagnosis / ICD codes
Treatment rendered / CPT codes
Prognosis
Functional limitations / restrictions
Work restrictions / return-to-work date
Medication list
Other (specify):

Specify date range for verification (if applicable): From to

Medical History Summary (for verification)

Sensitive Information

Disclosure of certain sensitive information requires explicit authorization. Check each box to authorize release of that category if requested:

Mental health records
HIV-related information
Substance use disorder treatment records
Genetic testing results

Purpose of Disclosure

Purpose of requested verification (select one or more):

Insurance claim / adjudication
Employment / leave of absence
Disability determination
Legal matter
Personal records
Other (explain):

Authorization and Certification

I hereby authorize the above-named provider/facility to disclose the health information specified in this request to the recipient named above for the purpose(s) stated. I understand that the information released may include summaries of treatment, diagnosis, dates of service, medications, and related clinical information. I understand that if I have authorized release of sensitive information as indicated above, such information may be included in the disclosure.

I understand that I may revoke this authorization at any time by submitting a written revocation to the provider, except to the extent that action has already been taken in reliance on this authorization. This authorization will expire on the date specified below or, if no date is specified, ninety (90) days from the date of my signature.

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand that reasonable fees may be charged for copying or preparing records and that the information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations.

Provider Verification Statement (to be completed by provider)

The undersigned provider verifies that the items checked above are accurate to the best of the provider's knowledge based on the patient's medical record. Provider may attach supporting documentation or office notes as appropriate.

By signing above, the signer affirms they are the patient or the patient's legal representative with authority to authorize disclosure as indicated herein.

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