OMB#:0925-0216
Expiration Date: xx/xxxx
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General Hospital
Medical Record Dept.
123 Main St.
Anytown, MA 00000
To Whom It May Concern:
As part of the research study of the National Heart, Lung
and Blood Institute, the Framingham Heart Study has been
studying the causes of coronary disease and stroke for nearly
fifty years. We are interested in completing our records on the
person listed below who has been a participant in our
long-term study.
Patient: Jane Doe ID# 0- 0
000 Main St.
Anytown, MA 00000 Date of Birth: 00/00/00
Date(s):
Records Requested:
___Face Sheet ___CT Scan (Head)
___Discharge Summary ___MRI/MRA (Head)
___ER Report ___Lab Rpts.–Cardiac Enzymes
___Admission Notes ___Consults Cardiac & Neuro
___Progress Notes ___Cardiac Catheterization
___Operative Reports ___Exercise Tolerance Test
___Pathology Reports ___Nursing Home Notes
___Chest X-Rays ___Notes near time of death
___EKGs (all) ___ _______________________
We would appreciate copies of the records requested. A return
envelope is enclosed for your convenience. The information you
provide will be kept confidential, and will not be disclosed to
anyone but the researchers conducting this study, except as
otherwise required by law.
Please use enclosed return envelope or send reply/information
To: Attn: MEDICAL RECORDS DEPARTMENT
Thank you for your kind assistance in this matter.
Sincerely yours,
Daniel Levy, M.D.
Medical Director
Framingham Heart Study
DL/lm
State Dept. of Vital Statistics
123 Main St.
Anytown, MA 00000
To Whom It May Concern:
As part of the research study of the National Heart, Lung
and Blood Institute in Framingham, Massachusetts into the
causes of coronary disease and stroke, we are interested
in completing our records on the person listed below who
was in our study and had died within your jurisdiction.
Name: John Doe ID# 0- 0
Date of Death: 00/00/00
Date of Birth: 00/00/00
We would appreciate a copy of the death certificate.
The information you provide will be kept confidential, and will
not be disclosed to anyone but the researchers conducting this
study, except as otherwise required by law.
Please use enclosed return envelope or send reply/information
to Attn: MEDICAL RECORDS DEPARTMENT
Thank you for your kind assistance.
Sincerely yours,
Daniel Levy, M.D.
Medical Director
Framingham Heart Study
DL/lm
Jane Smith, M.D.
123 Main St.
Anytown, MA 00000
Dear Doctor:
As part of the research study of the National Heart, Lung
and Blood Institute, the Framingham Heart Program has been
studying the causes of coronary disease and stroke for nearly
fifty years. We are interested in completing our records on the
person listed below who has been a participant in our
long-term study.
Patient: John Doe ID# 0- 0
0 Main St
Anytown, MA 00000
Date of Birth: 00/00/00
Records pertaining to
Date:
We would appreciate copies of the records requested. A return
envelope is enclosed for your convenience. The information you
provide will be kept confidential, and will not be disclosed
to anyone but the researchers conducting this study, except
as otherwise required by law.
Please use enclosed return envelope or send reply/information
To: Attn: MEDICAL RECORDS DEPARTMENT
Thank you for your kind assistance in this matter.
Sincerely yours,
Daniel Levy, M.D.
Medical Director
Framingham Heart Study
DL/lm
| File Type | application/msword |
| File Title | General Hospital |
| Author | lynne McDonald |
| Last Modified By | curriem |
| File Modified | 2010-09-09 |
| File Created | 2010-09-09 |