Sample Letter to Doctors

Place your contact info here that is onle with your doctor Address Cell phone Email

Hand delivered to my Doctor(s) I am increasingly concerned about privacy in the medical eld. Please place this letter at the top of my le. I wish to rescind anything in my medical records that I have signed in the past that would make you think it is permissable to share my medical records with other persons or entities without my express written permission. This letter superceeds anything else on le in that regard. I want to remind you of your Hippocratic oath and this concept summarized here:

Whatsoever things I see or hear concerning the life of men, in my attentance on the sick or even apart therefrom, which ought not be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets. Oath of Hippocrates, 4th Century, B.C.E.
I do not want my medical records entered into any data exchange(s), or shared with any other doctors, or shared with insurance companies other than the one I am currently with and have made you aware of with a copy of my card. Even then, that should be only what is information pertinent to billing questions for insurance purposes and nothing more. I want my medical decisions to be between you and I and not necessarily what my insurance provider thinks is appropriate. I want the costs to be fully disclosed and for you and I to make decisions together about what is appropriate. I do not want to be obligated to take your advice or forced into medical options at any point in time. I am seeking your best input and praying that you will have Godly wisdom for me. The decisions will be mine. Thank you for working with me on these matters and giving me your best care and advice possible. My condence is in the Lord. Sincerely, __________________ on Date: ____________________

Received by Dr. _________________

Name

Date

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Doctors with whom you may discuss my case on an as need basis:

List doctors here

My current insurance provider: List insurance providers here