Narrative Medical Report Request

NARRATIVE MEDICAL REPORT REQUEST

Request for Treating Physician Opinion

[LAW FIRM LETTERHEAD]

DATE: [________________________________]

VIA: [Mail / Fax / Email / Portal]

TO:

[PHYSICIAN NAME], [CREDENTIALS]
[PRACTICE/FACILITY NAME]
[ADDRESS]
[CITY, STATE ZIP]
[FAX: ________________]
[EMAIL: ________________]

RE: NARRATIVE MEDICAL REPORT REQUEST

Dear Dr. [PHYSICIAN NAME]:

As you know, this office represents [PATIENT NAME] regarding injuries sustained on [DATE OF INCIDENT]. We are preparing to present [his/her] claim and request your assistance in providing a narrative medical report summarizing your treatment and opinions.

I. PATIENT BACKGROUND

Mechanism of Injury:
[Describe the incident - e.g., "Patient was involved in a motor vehicle collision on [DATE]. Patient was the [driver/passenger] of a vehicle struck by another vehicle. Patient was wearing a seatbelt. Airbags [did/did not] deploy."]

Chief Complaints at Initial Presentation:
[________________________________]

Your Treatment Period:
[FROM DATE] through [TO DATE / Present]

II. RECORDS ENCLOSED

For your reference, we have enclosed copies of the following records:

☐ Your office treatment notes
☐ Hospital emergency room records
☐ Diagnostic imaging reports (X-ray, MRI, CT)
☐ Operative reports
☐ Physical therapy records
☐ Other treating physician records
☐ Prior medical records (for pre-existing condition review)
☐ Itemized billing

III. INFORMATION REQUESTED

Please prepare a narrative report addressing the following:

A. History and Examination

1. Date of initial examination following the incident
2. Patient's subjective complaints at initial presentation
3. Objective findings on physical examination
4. Relevant medical history and pre-existing conditions

B. Diagnosis

5. Please state all diagnoses related to the [DATE OF INCIDENT] incident
6. ICD-10 diagnosis codes for each condition

C. Causation

7. Within a reasonable degree of medical probability/certainty, please state whether the incident of [DATE] caused or substantially contributed to each diagnosed condition.

8. If the patient had pre-existing conditions, please explain how the incident aggravated or exacerbated those conditions.

9. Were the patient's injuries consistent with the described mechanism of injury?

D. Treatment Provided

10. Describe all treatment provided by your office
11. List all diagnostic testing ordered and results
12. List all medications prescribed
13. Were referrals made to other specialists? If so, to whom and why?
14. What was the total number of office visits?

E. Treatment by Others

15. Please comment on treatment provided by other providers, if relevant to your opinions

F. Current Status

16. What is the patient's current condition?
17. Has the patient reached maximum medical improvement (MMI)?
18. If not at MMI, what additional treatment is recommended?

G. Prognosis

19. What is your prognosis for the patient's recovery?
20. Is the patient's condition likely to be permanent?
21. Will the patient require future medical treatment? If so, please describe:
    - Type of treatment needed
    - Frequency of treatment
    - Duration of treatment
    - Estimated cost of future treatment

H. Functional Limitations

22. What functional limitations or restrictions, if any, does the patient have?
23. Are these limitations temporary or permanent?
24. How do these limitations affect the patient's daily activities?
25. How do these limitations affect the patient's ability to work?

I. Work Status

26. Was the patient taken off work? If so, for what period?
27. Was the patient placed on light duty/restricted work?
28. Is the patient currently able to work?
29. Are there any permanent work restrictions?

J. Additional Questions

30. [________________________________]
31. [________________________________]
32. [________________________________]

IV. REPORT FORMAT GUIDELINES

Please include the following in your report:

☐ Your full name, credentials, and specialty
☐ Date of report
☐ Patient identifying information
☐ Summary of records reviewed
☐ History of present illness/injury
☐ Physical examination findings
☐ Diagnoses with ICD-10 codes
☐ Treatment summary
☐ Causation opinion (within reasonable medical probability)
☐ Prognosis and future treatment needs
☐ Opinion on permanency
☐ Work status and restrictions
☐ Your signature and date

V. MEDICAL PROBABILITY STANDARD

Please note that your opinions should be stated "within a reasonable degree of medical probability" or "within a reasonable degree of medical certainty." This means that it is more likely than not (greater than 50% probability) that your opinion is accurate.

Opinions stated as "possible" or "might be" are generally insufficient for legal purposes.

VI. COMPENSATION

We have enclosed a check in the amount of $[________] for preparation of this report.

☐ Alternative: Please advise us of your fee for preparing this report and we will remit payment promptly.

Standard Fee Schedule:

VII. TIMELINE

We respectfully request that you provide the narrative report within [21-30] days if possible. If you require additional time or information, please contact us promptly.

Response Deadline Requested: [________________________________]

VIII. FUTURE TESTIMONY

Please note that you may be asked to provide testimony in this matter:

☐ Deposition testimony (oral testimony under oath, usually at an attorney's office)
☐ Trial testimony (testimony before a judge and/or jury)

If testimony is required, we will provide you with reasonable advance notice and discuss scheduling and fees.

IX. QUESTIONS OR CONCERNS

If you have any questions regarding this request, or if you require additional records or information, please contact:

[PARALEGAL/ATTORNEY NAME]
Phone: [________________________________]
Fax: [________________________________]
Email: [________________________________]

X. AUTHORIZATION

Enclosed please find a signed authorization from the patient permitting release of this information to our office.

Thank you for your assistance in this matter and for the excellent care you have provided to our client.

Very truly yours,

[SIGNATURE]

[ATTORNEY NAME]
Attorney for [PATIENT NAME]
[STATE BAR NUMBER]

Enclosures:
☐ HIPAA Authorization
☐ Medical Records
☐ Billing Records
☐ Check for Report Fee: $[________]
☐ Other: [________________________________]

PHYSICIAN RESPONSE TRACKING

For Law Firm Use:

SAMPLE NARRATIVE REPORT FORMAT

NARRATIVE MEDICAL REPORT

Date: [________________]

Re: [Patient Name]
DOB: [________________]
Date of Injury: [________________]

HISTORY OF PRESENT ILLNESS:
[Describe how patient presented, mechanism of injury, initial complaints]

PAST MEDICAL HISTORY:
[Relevant prior conditions]

PHYSICAL EXAMINATION:
[Objective findings]

DIAGNOSTIC STUDIES:
[X-rays, MRI, CT, EMG, etc. and findings]

DIAGNOSES:

1. [Diagnosis] - ICD-10: [Code]
2. [Diagnosis] - ICD-10: [Code]
3. [Diagnosis] - ICD-10: [Code]

TREATMENT PROVIDED:
[Summary of treatment]

CAUSATION:
Within a reasonable degree of medical probability, the above diagnoses were caused by the [DATE] incident.

PROGNOSIS:
[Expected recovery, permanency]

FUTURE TREATMENT:
[Description and estimated costs]

WORK STATUS:
[Restrictions, if any]

[Physician Signature]
[Printed Name, Credentials]
[Practice Name]
[Date]