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(Date of Letter)

(Hospital/Care Provider) (Street Address) (City, State and Zip Code) RE: Attn: Status Report Medical Records Department

Dear Medical Records Department: (month/year), until the (month/year), your facility treated (name of individual treated). At this time, the undersigned would appreciate a status report on the condition and care received by the aforementioned individual. It has been some time since any reports have been received relative to this individual's care and condition; therefore, in order for the undersigned's records to be complete, a status report is hereby requested. Kindly note the enclosed current patient waiver form. Should your office need any additional information from the undersigned, kindly advise. Thank you. From the day of day of

Very truly yours,

(Signature) (Address) (City, State and Zip Code) (Phone Number)

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