SAMPLE LETTER OF REPRESENTATION
SAMPLE LETTER OF REPRESENTATION
YOUR COMPANY LETTERHEAD
Date:
To Whom It May Concern:
This letter is to authorize Shield Data Network, LLC to facilitate the release of medical information on behalf of name of your agency . These documents are required for legal purposes (or state other reason).
Name of your agency and Shield Data Network, LLC are aware of the confidential nature of the personal health information being requested. The records being sought are for the sole purpose of the companies listed in this authorization.
This authorization shall remain in effect until further notice.
Please send records to:
Shield Data Network, LLC
Attention: Records Department
Fax #: (919) 321-1195
or
Mail to:
Shield Data Network, LLC
Records Department
P.O. BOX 12798
65 TW Alexander Drive
Durham, NC 27709
Sincerely,
[YOUR NAME]
[YOUR TITLE]
YOUR COMPANY LETTERHEAD
Date:
To Whom It May Concern:
This letter is to authorize Shield Data Network, LLC to facilitate the release of medical information on behalf of name of your agency . These documents are required for legal purposes (or state other reason).
Name of your agency and Shield Data Network, LLC are aware of the confidential nature of the personal health information being requested. The records being sought are for the sole purpose of the companies listed in this authorization.
This authorization shall remain in effect until further notice.
Please send records to:
Shield Data Network, LLC
Attention: Records Department
Fax #: (919) 321-1195
or
Mail to:
Shield Data Network, LLC
Records Department
P.O. BOX 12798
65 TW Alexander Drive
Durham, NC 27709
Sincerely,
[YOUR NAME]
[YOUR TITLE]