MEDICAL AND HOSPITAL RECORDS RELEASE AUTHORIZATION
TO: Massachusetts General Hospital
121 Innerbelt Road
Somerville, MA 02143
faxed also 617-726-3661
Thomas Dodson, MD
Massachusetts General Hospital
Oral and Maxillofacial
55 Fruit Street
Boston, MA 02114-2622
faxed also 617-724-8822
RE: Records of Patient: Bernard J. Wolfe, Jr. SS#, MGH# DOB
Office Address: PO Box 64, Woodsville, NH 03785 tel. 603-747-2338 Fax 603-747-3356 email email@example.com
Home Address: 1095 Woodsville Rd., Monroe, NH 03771, tel. 603-638-4401
I am sending this request for release of copies of my medical records to both above-named parties to assure obtaining said copies. My first request for records was dated June 20, 2003. I enclose a copy of my letter of July 25, 2003 mailed and faxed on July 25, 2003 which again requested copies of my records. Medical Records upon my call confirmed receipt of my fax.
This present request is being faxed and mailed certified mail/return receipt requested to both above named parties. I am also calling each today to determine if there are any charges for obtaining such copies.
This request for copies of medical records is to enable me to present such records to my health insurance company (Anthem) in order to obtain payment to Dr. Thomas Dodson and Massachusets General Hospital from my insurer for the services performed by Dr. Dodson and Massachusetts General Hospital.
You are hereby authorized to furnish and release to the person/entity/institution named herein at the addresses so set out herein copies of all medical records set forth covering findings, treatment rendered and opinions as to condition pertaining to evaluation of the injuries/damage to the right sinus, jaw and teeth. Any information and records regarding my condition is otherwise confidential and privileged and may not be disclosed without written authorization by me. This authorization shall remain in full force and effect until revoked by me in writing.
This request pertains to all communications to, with and/or from third parties relating to the sinus injuries, including hospitals, physicians, and staff. This includes possible treatment and diagnoses by Dr. Thomas Dodson based on an appointment on May 27, 2003 and later reading and evaluation of a CTScan films and reading furnished by Cottage Hospital as well as telephonic conferences with Dr. Connolly or members of his staff. Also including but not limited to all itemized bills, hospital records, Reports and notes on all evaluations, any surgical procedures, all x-rays, ultrasounds and related reports, all laboratory reports. This is to include panoramic films and reports.
DO NOT SEND THE ORIGINALS.
This does not include the copy of the CTscan performed at Cottage Hospital on June 9, 2003 and sent to Mass. General/Dr. Dodson.
Release exact duplicate copies of said records to:
Bernard J. Wolfe, Jr., PO Box 64, Woodsville, NH 03785
Anthem Blue Cross and Blue Shield, 3000 Goffs Falls Road, Manchester, NH 03111-0001,
Attention of Michelle A. Belyea, Appeal Specialist, Appeals Department.
Please also put inside on the records this same information so it will go to the correct department.
Dated: September 3, 2003
Bernard J. Wolfe, Jr.
Witness to BJW, Jr.