Dear Dr. Deroy/Dr. Duggirala:
This letter will authorize you to provide a copy, summary, or narrative of my medical records (as indicated by the check mark(s) below) or to otherwise release confidential information. At this time I am requesting the following:
I understand that you will provide this information within 15 business days from receipt of request, and you may charge a fee for preparing and furnishing this information.
The fee is waived because the records are to be used for supporting an application for Disability or other benefits or assistance under Aid to Families with dependent Children, Medicaid, Medicare, Supplemental Security Income, and Federal Old-Age and Survivors Insurance. I have attached a statement, which confirms that such an application or appeal has Been field or is pending.
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