Sample Foia Request Letter For Records On A Living Beneficiary From Someone Other Than The Beneficiary printable pdf download

Sample Foia Request Letter For Records On A Living Beneficiary From Someone Other Than The Beneficiary

SAMPLE FOIA REQUEST LETTER FOR RECORDS ON A LIVING

BENEFICIARY FROM SOMEONE OTHER THAN THE BENEFICIARY

To hasten the processing of your request, address your request to the CMS Regional Office

which has jurisdiction over the state where the beneficiary lives. The list of Regional Offices

and the respective states they have jurisdiction over can be found at:

A copy of the Health Insurance Portability and Accountability Act (HIPAA) authorization form

can be found at:

If the individual signing the valid authorization is not the beneficiary, then a Power of Attorney

must be provided.

Date

CMS FOIA Officer

(Address to the Regional Office as explained above)

Dear __________________:

Under the Freedom of Information Act, 5 U.S.C. subsection 552, I am requesting access to

[identify the records as clearly and specifically as possible].

[Optional] I am willing to pay fees for this request up to a maximum of $__. If you estimate that

the fees will exceed this limit, please inform me first.

[Optional] I request a waiver or reduction of all fees for this request the Department's FOIA

regulations at 45 C.F.R. 5.45. [Include specific details.]

[Optional] I request that the information I seek be provided in electronic format, and I would like

to receive it on a personal computer disk [or a CD-ROM].

[Optional] I ask that my request receive expedited processing because ____. [Include specific

details concerning your “compelling need.”]

[Optional] If you have any questions about handling this request, you may telephone me at

_________ [home / office / mobile phone.]

Sincerely,

Name

Address

Enclosures:

HIPAA Authorization

Power of Attorney (if applicable)

Sample Foia Request Letter For Records On A Living Beneficiary From Someone Other Than The Beneficiary