OMB Control Number: 0925-0216 Expiration Date: 10/2016
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Dear
Please accept our most sincere condolences on the death of
. We at the Framingham Heart Study appreciate her dedication to our research.
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, stroke, cancer and
other major diseases for over sixty years.
In order to review her record, we would like permission to
obtain copies of medical record(s) from the following:
Would you be willing to help us by signing the enclosed
authorizations(s) and sending a copy of the Power of Attorney/
Executor Appointment papers (if available) so that we can obtain
the medical record(s).
Please return it to us in the enclosed envelope at your earliest
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
Again, we offer our sincere condolences and are grateful
for your cooperation.
Sincerely yours,
Daniel Levy, M.D.
Medical Director
Framingham Heart Study
To Whom It May Concern:
I hereby authorize _________________________________________________
_________________________________________________
_________________________________________________
to release to the Framingham Heart Study
73 Mt. Wayte Avenue
Framingham, MA 01702
The following protected health information my medical record.
Patient Name: «FName» «MName» «LName» Date of Birth: «DOB»
Address: «Str1»
«Str2»
«City», «State» «Zip»
Disclose the following information for dates from «Evdate» to present.
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The purpose for this disclosure is research.
The information disclosed under this authorization will not be redisclosed to anyone but the researchers conducting this study, except as required by law.
I understand I may revoke this authorization at any time by requesting such of the above referenced physician/hospital in writing. If I do it will not have any effect on actions that the hospital/physician took before it received the revocation.
This authorization expires at the end of the research study.
Date: _______________________ Signed: __________________________
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, stroke, cancer and other major diseases for over sixty years. We are interested in completing our records on the person listed below who has been a participant in our long‑term study.
Patient:
Id#
Date of Birth:
Date of Death:
Date(s):
Records Requested:
___Face Sheet ___CT Scans
___Discharge Summary ___MRI/MRAs
___ER Report ___EEG
___Admission Notes ___Ultrasound
___Progress Notes ___Lab Reports ‑ Cardiac Enzymes
___Operative Reports ___Consults (Cardiac and Neuro)
___Pathology Reports ___Cardiac Catheterization
___X‑Rays ___Nursing Home Notes
___Echocardiogram ___Notes near time of death
___Exercise Tolerance Test ___Pronouncement Note
___EKGs with rhythm tracings graph (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
Xxxx Xxxxx
000 Xxxx Xx.
Xxxxxxx, XX 00000
Dear Xxxx Xxxxx,
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 heart disease and stroke for
over sixty years.
As you know, Xxxxxx Xxx was a participant
in the Heart Study. In order to review her record, we would
like permission to obtain copies of her medical record(s)
from the following:
Xxxxxxx Xxxxxxxx.
Would you be willing to help us by signing the enclosed
authorizations(s) sending a copy of the Power of Attorney/
Executor Appointment papers(if available) so that we can obtain
the medical record(s).
Please return it to us in the enclosed envelope as soon
as possible. 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
We will be most grateful for your cooperation.
Sincerely yours,
Daniel Levy, M.D.
Medical Director
Framingham Heart Study
TO WHOM IT MAY CONERN:
I hereby authorize _________________________________________________
_________________________________________________
_________________________________________________
to release to the Framingham Heart Study
73 Mt. Wayte Avenue
Framingham, MA 01702
The following protected health information my medical record.
Patient Name: «FName» «MName» «LName» Date of Birth: «DOB»
Address: «Str1»
«Str2»
«City», «State» «Zip»
Disclose the following information for dates from «Evdate» to present.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
The purpose for this disclosure is research.
The information disclosed under this authorization will not be redisclosed to anyone but the researchers conducting this study, except as required by law.
I understand I may revoke this authorization at any time by requesting such of the above referenced physician/hospital in writing. If I do it will not have any effect on actions that the hospital/physician took before it received the revocation.
This authorization expires at the end of the research study.
Date: _______________________ Signed: __________________________
____________________________ _________________________________
PRINTED NAME RELATIONSHIP TO PATIENT OR
AUTHORITY TO ACT FOR PATIENT
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Barbara Inglese |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |