Form 2 Attachment 5 Medical Record Request

The Framingham Study (NHLBI)

Attach 5 Medical Record Request

Participant Components Annual follow-up records Request

OMB: 0925-0216

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OMB Control Number: 0925-0216 Expiration Date: 10/2016

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.




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.


  • Face Sheet

  • CT Scan (Head)

  • Discharge Summary

  • MRI/MRA (Head/Neck)

  • ER Report

  • Lab Reports – Cardiac Enzymes

  • Admission Notes

  • Consults (Cardiac & Neuro)

  • Progress Notes

  • Cardiac Catheterization

  • Operative Report

  • Exercise Tolerance Test

  • Pathology Report

  • Nursing Home Notes

  • Chest X-Ray

  • Notes near time of death

  • EKGs (All)

  • Pronouncement Note

  • Echocardiogram


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.


  • Face Sheet

  • CT Scan (Head)

  • Discharge Summary

  • MRI/MRA (Head/Neck)

  • ER Report

  • Lab Reports – Cardiac Enzymes

  • Admission Notes

  • Consults (Cardiac & Neuro)

  • Progress Notes

  • Cardiac Catheterization

  • Operative Report

  • Exercise Tolerance Test

  • Pathology Report

  • Nursing Home Notes

  • Chest X-Ray

  • Notes near time of death

  • EKGs (All)

  • Pronouncement Note

  • Echocardiogram


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

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