A6a Records Request Form

OMB #: 0925–0216
Expiration Date: xx/xxxx

Public reporting burden for this collection of information is estimated to average 15 minutes
per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0216). Do not return
the completed form to this address.

OMB #: 0925–0216
Expiration Date: xx/xxxx

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:

ID#

Date of Death:
Date of Birth:

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

OMB #: 0925–0216
Expiration Date: xx/xxxx

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:

ID#

Date of Birth:
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

OMB #: 0925–0216
Expiration Date: xx/xxxx

Dear
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 fifty years.

As you know,
is a participant
in the Heart Study. In order to review his record, we would
like permission to obtain copies of his 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 paper (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,

DL/lm
OMB # 0925-0216

Daniel Levy, M.D.
Medical Director
Framingham Heart Study

OMB #: 0925–0216
Expiration Date: xx/xxxx

TO WHOM IT MAY CONCERN:
I hereby authorize
to release to the Framingham Heart Study
73 Mt Wayte Ave.
Framingham, MA 01702
the following protected health information from
medical record.
Patient Name:
Address:

Date of Birth:

Disclose the following information for dates:

*
*
*
*
*
*
*
*
*
*

Face Sheet
Discharge Summary
ER Report
Admission Notes
Progress Notes
Operative Report
Pathology Report
Chest X-Rays
EKGs (All)
Echocardiogram

*
*
*
*
*
*
*
*
*

CT Scan (Head)
MRI/MRA (Head/Neck)
Lab Reports - Cardiac Enzymes
Consults (Cardiac & Neuro)
Cardiac Catheterization
Exercise Tolerance Test
Nursing Home Notes
Notes near time of death
Other _______________________
_____________________________

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

OMB # 0925-0216

OMB #: 0925–0216
Expiration Date: xx/xxxx

,
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(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
DL/dc

OMB #: 0925–0216
Expiration Date: xx/xxxx

Dear
As part of the research study of the National Heart, Lung
and Blood Institute in Framingham, Massachusetts into the
causes of heart disease and stroke, we are interested in
updating our records on you. In order to do that we would
like to obtain a copy of your medical records from the
following:

Could you please help us by signing the authorization
form(s) and returning 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 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
DL/lm
OMB # 0925-0216

OMB #: 0925–0216
Expiration Date: xx/xxxx

TO WHOM IT MAY CONCERN:
I hereby authorize
to release to the Framingham Heart Study
73 Mt Wayte Ave.
Framingham, MA 01702
the following protected health information from my
medical record.
Patient Name:
Address:

Date of Birth:

Disclose the following information for dates:

*
*
*
*
*
*
*
*
*
*

Face Sheet
Discharge Summary
ER Report
Admission Notes
Progress Notes
Operative Report
Pathology Report
Chest X-Rays
EKGs (All)
Echocardiogram

*
*
*
*
*
*
*
*
*

CT Scan (Head)
MRI/MRA (Head/Neck)
Lab Reports - Cardiac Enzymes
Consults (Cardiac & Neuro)
Cardiac Catheterization
Exercise Tolerance Test
Nursing Home Notes
Notes near time of death
Other _______________________
_____________________________

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: ___________________
OMB # 0925-0216
E

SIGNED: _______________________

OMB #: 0925–0216
Expiration Date: xx/xxxx

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
DL/lm

OMB #: 0925–0216
Expiration Date: xx/xxxx

TO WHOM IT MAY CONCERN:
I hereby authorize
to release to the Framingham Heart Study
73 Mt Wayte Ave.
Framingham, MA 01702
the following protected health information from
medical record.
Patient Name:
Address:

Date of Birth:

Disclose the following information for dates:
*
*
*
*
*
*
*
*
*
*
*
*

Face Sheet
* CT Scan(s)
Discharge Summary
* MRI/MRA(s)
ER Report
* Lab Reports - Cardiac Enzymes
Admission Notes
* Consults (Cardiac & Neuro)
Progress Notes
* Cardiac Catheterization
Operative Report
* Exercise Tolerance Test
Pathology Report
* Carotid Ultrasound
Chest X-Rays
* EEG
EKGs (All)
* Nursing Home Notes
Echocardiogram
* Notes near time of death
Holter Monitor
* Pronouncement Note
Other ________________________________________________

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