MESA
Manual of Operations Sample
Letters for MESA Events Appendix
E, Page
The following letters are samples/templates for letters/requests you may need to send to outside resources (i.e., proxies, physicians, coroners, etc.) to obtain participant medical records and other documentation pertinent to MESA events ascertainment. Please note you are not required to use these formats, but, rather these letters may be used as guidelines to help ensure pertinent information is requested from each source.
The following sample letters are included in this appendix:
E.2.1. HOSPREL Hospital medical record release form
E.2.2. HOSPCOV Cover letter to hospital to obtain medical records
E.2.3 PHYSREL Physician/clinic record release form
E.2.4 PHYSCOV Cover letter to physician/clinic to obtain medical records
E.2.5 MELET Cover letter to next of kin to obtain medical examiner/coroner reports
E.2.6 MEREL Medical examiner record release form
E.2.7 MECOV Cover letter to medical examiner to obtain ME/coroner reports
E.2.8 PQCERT PQ cover letter to physician signing death certificate
E.2.9 PQATND PQ cover letter to attending physician of decedent
E.2.10 PQCLIN PQ cover letter to medical clinic of decedent
E.2.11 INFLET Letter to informant/next of kin, known telephone number
E.2.12 INFNONUM Letter to informant/next of kin, unknown telephone number
E.2.13 RETNUM Reply postcard from informant/next of kin with telephone number
E.2.14 INFNEIGH Letter to neighbor of decedent
E.2.15 RETNEIGH Reply postcard from neighbor of decedent
MESA STUDY HOSPITAL MEDICAL RECORD RELEASE FORM
Patient: [participant name]
[participant street address]
[participant city, state zip]
Hospital: [hospital name]
[hospital street address]
[hospital city, state zip]
Please release to the Multi-Ethnic Study of Atherosclerosis (MESA):
All records of hospitalizations which occurred during the period [time between clinic visit and follow-up phone call 1].
I authorize the above agency to release copies of my medical records to the [institution], MESA. This information will be used to statistical purposes only, and will remain strictly confidential.
_______________________________________ _____________________
Signature of Patient Date
[date]
[hospital name]
[hospital street address]
[hospital city, state zip]
Dear Correspondence Clerk:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution], along with five other centers in the United States.
[participant] (date of birth [date of birth]), a participant in our study, was a patient at [hospital name] during [year]. Enclosed you will find a release of medical information signed by [next of kin name]. We are needing medical records involving that hospitalization including ER report, History and Physical, Discharge ICD-9 codes, Discharge Summary, Progress Notes, ECGs and Enzyme reports, and all other test and procedure results.
If you have any questions, please feel free to call NAME, our local Surveillance Supervisor, at PHONE NUMBER.
This information will be used for statistical purposes only, and will remain strictly confidential. Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
MESA STUDY PHYSICIAN/CLINIC RECORD RELEASE FORM
Patient: [participant name]
[participant street address]
[participant city, state zip]
Hospital: [doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]
Please release to the Multi-Ethnic Study of Atherosclerosis (MESA):
All records of diagnoses and procedures that occurred during the period [time between clinic visit and follow-up phone call 1].
I authorize the above agency to release copies of my medical records to the [institution], MESA. This information will be used to statistical purposes only and will remain strictly confidential.
_______________________________________ _____________________
Signature of Patient Date
[date]
[doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]
Dear Correspondence Clerk:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution], along with five other centers in the United States.
[participant] (date of birth [date of birth]), a participant in our study and your patient, reported being under your care during [year]. Enclosed you will find a release of medical information signed by [next of kin name]. We are needing medical records involving diagnoses and procedures including History and Physical, Discharge ICD-9 codes, Discharge Summary, Progress Notes, ECGs and Enzyme reports, and all other test and procedure results.
If you have any questions, please feel free to call NAME, our local Surveillance Supervisor, at PHONE NUMBER.
This information will be used for statistical purposes only, and will remain strictly confidential. Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
[date]
[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing with regard to our telephone interview on [date] regarding [participant]. Your information has been extremely valuable to the Multi-Ethnic Study of Atherosclerosis (MESA). Thank you.
[participant]’s death was investigated by the County Medical Examiner’s Office. With your permission, the MESA would like to review those records to confirm the medical details. The Medical Examiner requires a written consent for release of medical information. Would you please sign the enclosed consent form for the Medical Examiner and return it to us in the enclosed stamped envelope?
Please note your consenting to the release of this information is completely voluntary and, if you choose to not offer us your consent, it will in no way affect any relationship you may have with this institution. If you have any questions, please feel free to call NAME at PHONE NUMBER.
Thank you again for your help in this matter.
Sincerely,
NAME
MESA Study Coordinator
NAME
Principal Investigator
Enclosures: Release Form and Return Envelope
MESA STUDY MEDICAL EXAMINER RECORD RELEASE FORM
Patient: [participant name]
[participant street address]
[participant city, state zip]
County: [county name]
I, [contact/next of kin name], the closest relative of [participant], who is deceased, give permission for the County Medical Examiner to release medical information to the [institution], Multi-Ethnic Study of Atherosclerosis (MESA). This information will be used to statistical purposes only, and will remain strictly confidential.
_______________________________________ _____________________
Signature of Next of Kin Date
[date]
[medical examiner name]
[street address]
[city, state zip]
Dear [medical examiner name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States.
We are needing information on [participant], who died on [date of death], and whose death was listed as a Medical Examiner case. MESA requests a copy of the Medical Examiner’s report. A consent form signed by his/her next of kin is enclosed.
This information will be used for statistical purposes only, and will remain strictly confidential. If you have any questions, please feel free to call NAME, our local Surveillance Supervisor, at PHONE NUMBER. Thank you very much in advance for your kind assistance and consideration of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Release Form
[date]
[physician name]
[street address]
[city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States.
We are needing information on [participant], who died on [date of death], and whose death certificate you signed on [date]. The information is needed to supplement the death certificate in assigning a cause of death. Could you or your nurse take a few moments to provide from your records the answers to the questions on the enclosed form?
This information will be used for statistical purposes only, and will remain strictly confidential. Of course, your participation is entirely voluntary, and, if you choose to not complete and return this form, it will in no way affect any relationship you may have with this institution. If you have any questions, please feel free to call me collect, at PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE NUMBER. Thank you very much in advance for your kind assistance and consideration of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
[date]
[physician name]
[street address]
[city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States.
We are needing information on [participant], who died on [date of death], and who, according to the family, was your patient. The information is needed to supplement the death certificate in assigning a cause of death. Could you or your nurse take a few moments to provide from your records the answers to the questions on the enclosed?
This information will be used for statistical purposes only, and will remain strictly confidential. Of course, your participation is entirely voluntary, and, if you choose to not complete and return this form, it will in no way affect any relationship you may have with this institution. If you have any questions, please feel free to call me collect, at PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE NUMBER. Thank you very much in advance for your kind assistance and consideration of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
[date]
[doctor’s office or clinic name]
[doctor’s office or clinic street address]
[doctor’s office or clinic city, state zip]
Dear [physician name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States.
We are needing information on [participant], who died on [date of death], and who, according to the family, was a patient at [doctor’s office or clinic name]. The information is needed to supplement the death certificate in assigning a cause of death. Could you or your nurse take a few moments to provide from your records the answers to the questions on the enclosed form?
This information will be used for statistical purposes only, and will remain strictly confidential. Of course, your participation is entirely voluntary, and, if you choose to not complete and return this form, it will in no way affect any relationship you may have with this institution. If you have any questions, please feel free to call me collect, at PHONE NUMBER, or our local Surveillance Supervisor, NAME, at PHONE NUMBER. Thank you very much in advance for your kind assistance and consideration of this request.
Sincerely,
NAME
Principal Investigator
Enclosure: Physician Questionnaire
[date]
[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States, to ask for your help.
Your name is listed on the death certificate of [participant name] who passed away on [date of death]. In a few days a member of my staff will be calling to explain further about the project and seek your permission to ask a few medical questions.
The information you provide will be used for statistical purposes only, and will remain strictly confidential. Of course, your participation is entirely voluntary, and, if you choose to not speak with us on this matter, it will in no way affect any relationship you may have with this institution.
Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
[date]
[contact/next of kin name]
[street address]
[city, state zip]
Dear [contact/next of kin name]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States, to ask for your help.
Your name is listed on the death certificate of [participant name] who passed away on [date of death]. We would like to call you to explain more about the project and to ask a few medical questions, but have been unable to find your telephone number.
Could you take a few moments to fill out and mail the enclosed postcard?
The information we will be calling about will be used for statistical purposes only, and will remain strictly confidential. Of course, your assistance in our research is entirely voluntary, and, if you choose to not provide your phone number and speak with us on this matter, it will in no way affect any relationship you may have with this institution
Thank you very much in advance for your help in the important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Return Postcard
POSTCARDS SHOULD BE RETURN-ADDRESSED TO LOCAL SURVEILLANCE CENTER AND STAMPED.
Dear [name of Surveillance Supervisor]:
I will be able to help with you with the Multi-Ethnic Study of Atherosclerosis (MESA).
_____ I do have a telephone number which is __ __ __ - __ __ __ - __ __ __ __ .
The best times to reach me are __ __ __ __ or __ __ __ __ .
An alternative telephone number is __ __ __ - __ __ __ - __ __ __ __ .
The best times to reach me at this number are __ __ __ __ or __ __ __ __.
_____ I do not have a telephone number, but I agree to be interviewed in person.
I will be calling your staff to set up a time and a place for the interview.
Sincerely,
_____________________
[date]
[neighbor name]
[street address]
[city, state zip]
Dear [neighbor]:
I am writing on behalf of the Multi-Ethnic Study of Atherosclerosis (MESA), an epidemiologic project of the [institution] along with five other centers in the United States, to ask for your help.
As you may know, [participant name] passed away on [date of death]. As part of the study, we are systematically attempting to contact a next-of-kin or another person who lived with the decedent in order to obtain some medical information that would help us to find out about the circumstances surrounding [participant name]’s death. We have not been able to locate such a person and since you were [participant name]’s neighbor, we believe that you may be able to help us do so.
Could you take a few moments to fill out and mail the enclosed postcard?
The information we wish to obtain from the next-of-kin or other person who lived with [participant name] will be used for research purposes only, and will remain strictly confidential. Of course, your assistance in this matter is entirely voluntary, and, if you choose to not speak with us on this matter, it will in no way affect any relationship you may have with this institution
Thank you very much in advance for your help in this important study.
Sincerely,
NAME
Principal Investigator
Enclosure: Return Postcard
POSTCARDS SHOULD BE RETURN-ADDRESSED TO LOCAL SURVEILLANCE CENTER AND STAMPED.
Dear [name of Surveillance Supervisor]:
The following individual(s) was (were) living with [participant name] at the time of his/her death:
Name |
Relationship to deceased |
Present address |
Present telephone number |
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I do not have any information on persons who were living with [participant name] at the time of his/her death.
Sincerely,
_________________________
| File Type | application/msword |
| File Title | February, 2003 |
| Author | sharon |
| Last Modified By | olsonj |
| File Modified | 2007-10-05 |
| File Created | 2007-10-05 |