Form No number No number Appendix S.1 Medical Record Request and Script

Medical Record Request Script for Contacting Medical Providers

For Primary Care Provider/OB-GYN:

Hello, my name is <name>. I am calling from <site>. As part of one of our research studies, one of your patients signed a HIPAA medical release form authorizing us to get their entire medical record. I can fax you the medical release form. What is your fax number and address? I am going to fax you the form now. Please see the cover letter that I’m going to send with the medical release form for information on how to send us the medical record. If you should have any further questions, my contact information is in the cover letter.

Thank you for your assistance.

For Pediatrician:

Hello, my name is <name>. I am calling from <site>. As part of one of our research studies, the mother of one of your patients signed a HIPAA medical release form authorizing us to get the entire medical record for her child. I can fax you the medical release form. What is your fax number and address? I am going to fax you the form now. Please see the cover letter that I’m going to send with the medical release form for information on how to send us the medical record. If you should have any further questions, my contact information is in the cover letter.

Thank you for your assistance.

<Name of provider>

<Address 1>

<Address 2>

<Date>

Dear <provider>,

The mother of one of your patients is participating in one of our research studies and has granted us permission to view her child’s medical record. Enclosed you will find a signed release of health information form for <child’s name>. Please provide a copy of the patient’s entire medical record.

Please mail the requested medical record documents to the following address:

<Project Coordinator>

<Address 1>

<Address 2>

<Address 3>

If there is a charge associated with this request, please contact me by telephone at

<phone number> and we will send a check to cover the service. Please do not bill the patient.

If you have any questions or need additional information, please do not hesitate to contact me. Thank you for your timely response to this request.

Sincerely,

<Project Coordinator>

<Name of provider>

<Address 1>

<Address 2>

<Date>

Dear <provider>,

One of your patients is participating in one of our research studies and has granted us permission to view her medical record. Enclosed you will find a signed release of health information form for <mother’s name>.

Please provide a copy of all the documents in the patient’s medical record that pertain to her prenatal care and labor and delivery during her pregnancy with <child’s name>. <child’s name> was born on < child’s birthdate>.

Please mail the requested medical record documents to the following address:

<Project Coordinator>

<Address 1>

<Address 2>

<Address 3>

If there is a charge associated with this request, please contact me by telephone at

<phone number> and we will send a check to cover the service. Please do not bill the patient.

If you have any questions or need additional information, please do not hesitate to contact me. Thank you for your timely response to this request.

Sincerely,

<Project Coordinator>

Appendix S1