Legal DVT Letter

LEGAL DVT LETTER

Date:     Patient Name:     Patient DOB:

Claimant (if different):     Employer/Recipient:     Claim/Reference No.:

RECITALS

WHEREAS, Patient Name: has received medical care from Medical Provider: and has been diagnosed with deep vein thrombosis (DVT); and

WHEREAS, the parties seek to document the medical findings, functional limitations, recommended work restrictions and reasonable accommodations related to the DVT diagnosis for purposes of claims administration, workplace accommodation, or settlement; and

WHEREAS, the Recipient (Employer/Insurer) and Claimant/Patient agree that a written statement prepared in accordance with applicable medical and legal standards is an appropriate record to guide accommodation and claims decisions.

NOW THEREFORE

In consideration of the mutual promises contained herein and other good and valuable consideration, the parties agree as follows:

1. DEFINITIONS

For purposes of this Letter, "DVT" shall mean deep vein thrombosis as diagnosed by a licensed medical practitioner; "Provider" shall mean the medical professional identified in this Letter; "Recipient" shall mean Employer or Insurer identified above; and "Claimant" shall mean the patient or person asserting rights under this Letter.

2. MEDICAL FINDINGS

The Provider certifies that the Claimant has been evaluated and that the following findings are accurate and supported by the Provider's medical records. Summary of findings:

3. FUNCTIONAL LIMITATIONS AND RESTRICTIONS

Based on the current clinical assessment, the Provider recommends the following functional limitations and restrictions which are reasonably related to the DVT diagnosis:

Duration of restrictions: From to .

4. WORK ACCOMMODATIONS & RECOMMENDATIONS

The Provider recommends the following accommodations which are reasonable and necessary to facilitate return to work or to prevent exacerbation of the condition. Select applicable items and describe as needed:

Light duty assignment    Frequent positional changes/rest breaks    Compression garments/medical equipment recommended

5. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

Claimant authorizes the Provider to release relevant medical records and clarifying information to the Recipient for the limited purpose of claims adjudication, accommodation decisions, or settlement. The scope of this authorization is limited to records and communications reasonably necessary to verify diagnosis, treatment, restrictions and prognosis.

Expiration of authorization: or upon conclusion of the related claim, whichever occurs first.

6. CONFIDENTIALITY

Records or disclosures made pursuant to this Letter shall be treated as confidential medical information. Recipient shall limit access to authorized personnel on a need-to-know basis and shall not disclose medical details beyond what is reasonably necessary for claims handling or accommodation.

7. REPRESENTATIONS AND WARRANTIES

Provider represents that the statements and recommendations made in this Letter are made in good faith, are based on current medical records and examination, and to the best of Provider's knowledge are true and accurate. Claimant represents that the information provided to Provider for the purpose of this assessment is accurate.

8. INDEMNIFICATION

To the extent permitted by law, the Recipient shall not rely on the Provider's statements beyond the limited purpose stated herein and shall indemnify and hold harmless Provider from claims arising from Recipient's implementation of accommodations or work restrictions inconsistent with authoritative medical direction. This provision does not limit any statutory rights of the Claimant.

9. NOTICES

10. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Letter shall be governed by and construed in accordance with the substantive laws of the state selected by the parties for claim administration. The parties agree that this Letter constitutes the entire written agreement between the parties with respect to the subject matter hereof and supersedes all prior or contemporaneous oral or written agreements. If any provision of this Letter is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

11. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Letter must be in a signed writing by authorized representatives of both parties. Failure to enforce any provision shall not constitute a waiver of that provision. This Letter may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. ACKNOWLEDGMENTS

By signing below, the parties acknowledge that they have read and understood the foregoing statements, that the statements are true to the best of their knowledge, and that they have authority to enter into this Letter.

Sign Now