Client Request for Medical Records, Forms, or Letters

Client Request for Medical Records, Forms, or Letters

Please use this form to submit your request for the following: medical records, letters prepared by your therapist, or other forms needing to be completed. This is a secure form and is only intended for the purposes of informing Elliott Counseling Group of your request. DISCLAIMER: Submitting this form does guarantee our agency will be able to fulfill this request. Upon submission of your request, you will be contacted by a member of our administrative team to arrange a deposit to begin this process. Deposits will be equal to half of the total cost for the letter/form and are non-refundable. If your therapist determines that they are unable to meet the request, you will be contacted and refunded your deposit.

GENERAL FEE RATES: (subject to change)

Letters from Therapist.............................................$70

Emotional Support Animal Letter.............................$120

Simple Form (1 page or less)...................................$70

In-Depth Forms (2+ pages)......................................$120

Medical Records (Cost waived for clients UNLESS they have a past due balance)

IMPORTANT NOTE: Requested materials will be ready within two weeks of the day that you request it unless you state that you need it by a different date. If the letter/form is needed in less than two weeks, there is a $12 fee, if needed in less than one week, it is $24. We cannot guarantee that we can produce a letter in less than a week. Our medical records specialist will email you an invoice with the final cost. A Non-Refundable deposit is required to begin this request, and all fees are required to be paid before the materials are released.

Today's Date*

LETTER REQUEST

EMOTIONAL SUPPORT ANIMAL LETTER REQUEST

FORMS/EVALUATIONS

SEND RECORDS TO OUTSIDE PROVIDER OR CLIENT

REQUEST RECORDS FROM OUTSIDE PROVIDER

Is this needed for legal or court purposes?

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Client Name*

Clients DOB*

Clients Email Address*

Provider Name*

Requested Due Date*

Letters and forms will be completed in two weeks. If you need it sooner, we will speak with your provider to determine how early they can have it completed. There is an additional fee for expedited letters and forms.

Recipient's Contact Information*

Please provide the name and contact information of the person or organization that you would like the letter/records/form sent to. Fax, email, or postal mail are available.

Have you spoken with your provider?*

Please note, we strongly encourage you to discuss this request with your therapist prior to submitting this request as it requires a non-refundable deposit. Elliott Counseling Group reserves the right to deny any form or letter request if the provider or agency do not find that the client meets the clinical needs of the request or find it clinically inappropriate. We will not refund deposits for denied requests if you have not previously spoken with your provider before submitting the request.

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Additional Notes*

To best serve you, please provide as much detail as possible regarding the materials you are requesting to make sure that your request is completed accurately. If we need more information, we will be in touch with you. Examples of what is needed: what do you need the letter for, fax numbers, who is the letter/forms going to, what is the address for where it needs to be sent, etc.

Payment Option*

A deposit of 50% of the cost must be paid before your provider can begin writing a letter or filling out forms. Please see pricing at the top of this form.

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Who is submitting this request?*

File Attachments

If you have a form or document for your therapist to fill out, please attach it here:

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