# Template Letter: Requesting Childhood Medical Records for Kobe

**Purpose:** Request medical records from childhood providers to document developmental delays, diagnoses, and functional limitations for VA dependent benefits claim.

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## Template for Pediatrician / Primary Care Provider

**[Date]**

**[Provider Name / Medical Records Department]**  
**[Clinic/Hospital Name]**  
**[Address]**  
**[City, State ZIP]**

**Re: Medical Records Request for [Kobe's Full Legal Name]**  
**Date of Birth:** [MM/DD/YYYY]  
**Patient ID / Account #:** [if known]

Dear Medical Records Department,

I am requesting a complete copy of medical records for my son, **[Kobe's Full Legal Name]**, who was a patient at your facility from approximately **[start year]** to **[end year]**.

### Purpose of Request
These records are needed to support a **VA dependent benefits claim** for my son, who has a permanent disability. The Department of Veterans Affairs requires documentation of:
- Developmental delays and milestones
- Diagnoses and treatment history
- Functional limitations and impairments
- Educational accommodations and services

### Records Requested
Please provide **all available records** including:

**Clinical Documentation:**
- [ ] Complete medical history and physical exams
- [ ] Well-child visit notes (all ages)
- [ ] Sick visit notes and acute care records
- [ ] Growth charts and developmental screening results
- [ ] Immunization records

**Diagnostic Records:**
- [ ] Psychological evaluations
- [ ] Developmental assessments
- [ ] Speech/language evaluations
- [ ] Occupational therapy evaluations
- [ ] Any IQ testing or cognitive assessments
- [ ] Lab results and diagnostic test reports

**Specialist Referrals:**
- [ ] Referral letters to specialists
- [ ] Specialist consultation notes
- [ ] Treatment recommendations
- [ ] Follow-up documentation

**Educational/Developmental:**
- [ ] School health records (if maintained by your office)
- [ ] Letters documenting need for special education
- [ ] Documentation of developmental delays
- [ ] Functional limitation assessments

**Medication History:**
- [ ] Prescription records
- [ ] Medication management notes
- [ ] Response to treatment documentation

### Specific Timeframes of Interest
**Early Childhood (Birth - Age 5):**  
Documentation of when delays were first noticed, early intervention services, developmental milestone tracking.

**School Age (Age 5 - Present):**  
Ongoing treatment, educational impact, functional limitations, progression of condition.

### Preferred Format
- [ ] **Electronic records** (PDF via secure email to: [your email])
- [ ] **Paper copies** (mailed to address below)
- [ ] **CD/USB** (mailed to address below)

### Authorization and Release

**Patient Information:**
- Full Name: [Kobe's Full Legal Name]
- Date of Birth: [MM/DD/YYYY]
- Social Security Number: [XXX-XX-XXXX] (optional, for identification)
- Address: [Kobe's current address]

**Requesting Party:**
- Name: [Your Full Name]
- Relationship: Father / Legal Guardian
- Phone: [Your Phone Number]
- Email: [Your Email]
- Address: [Your Mailing Address]

**Purpose:** VA Dependent Benefits Claim Documentation

**I authorize the release of the above medical records to:**
- Frederick Book (parent/legal guardian)
- AND/OR directly to: Department of Veterans Affairs

**Signature:** ________________________________  
**Printed Name:** [Your Full Name]  
**Date:** _______________

**Notarization:** *(if required - check with provider)*

---

### Delivery Address
**Mail records to:**  
Frederick Book  
[Your Street Address]  
[City, State ZIP]

**Questions? Contact me at:**  
Phone: [Your Number]  
Email: [Your Email]

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## Additional Notes

**Timeline:**
- Allow 30-45 days for processing (HIPAA allows up to 30 days, but extensions are common)
- If records are urgent, note "TIME-SENSITIVE: VA CLAIM DEADLINE [date]"

**Fees:**
- Most providers charge per-page copying fees (typically $0.50-1.00/page)
- Some charge administrative fees ($25-50)
- Ask about fee waiver for VA benefits purposes
- Some states limit medical record fees - check Illinois law

**Follow-Up:**
- Call 10-14 days after mailing to confirm receipt
- Get name of person handling request
- Ask for estimated completion date
- Keep copy of request letter for your records

**If Provider No Longer Exists:**
- Check with state medical board for record custodian
- Contact hospital system if practice was acquired
- Try state health department archives

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## Providers to Contact

**Create a tracking list:**

| Provider Name | Dates Seen | Request Sent | Follow-Up | Received |
|---------------|------------|--------------|-----------|----------|
| [Pediatrician Name] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |
| [Specialist Name] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |
| [Hospital/Clinic] | [Years] | [ ] ___/___/___ | [ ] ___/___/___ | [ ] ___/___/___ |

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## Key Points to Emphasize

**What VA Needs to See:**
1. **When** the disability began (early childhood preferred)
2. **What** the diagnoses are (formal, from medical professionals)
3. **How** it affects daily function (ADLs, learning, social skills)
4. **Progression** over time (stable vs. worsening)
5. **Treatment history** (medications, therapies, interventions)

**Timeline is Critical:**
- VA wants to see the disability existed **before age 18** (or before age 23 if in school)
- Earlier documentation = stronger claim
- Continuous treatment history shows permanence

**What Makes Records Valuable:**
- Specific diagnoses with DSM/ICD codes
- Functional assessments (what child can/can't do)
- Developmental milestone delays documented
- Need for special education services
- Comparison to age-appropriate norms
- Provider statements about permanence/prognosis

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## Sample Follow-Up Phone Script

**When calling to check status:**

"Hi, I'm calling to follow up on a medical records request I sent on [date] for my son [Kobe's name], date of birth [DOB]. 

The request is for VA dependent benefits documentation, so it's fairly time-sensitive. 

Can you tell me:
1. Have you received my request?
2. What's the estimated completion date?
3. Is there anything else you need from me?
4. What will the cost be?

Thank you!"

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## If Records Are Incomplete

**What to do if provider says "we don't have that":**

1. **Ask specifically** what they DO have
2. **Request index/summary** of available records
3. **Ask about storage/archive** - older records may be off-site
4. **Get statement** documenting what's missing (helps explain gaps to VA)

**Sample request:**
"If you don't have the complete records, could you please provide:
- A summary of what you DO have
- Dates of service you can verify
- A statement documenting that records prior to [year] are no longer available

This will help explain the gap in documentation to the VA."

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## Privacy Tip

**HIPAA Right of Access:**
- You have absolute right to your child's medical records
- Providers MUST provide them (with limited exceptions)
- 30-day response time is federal law
- If denied, ask for written explanation and escalate to state health department

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**This template is ready to customize and send. Fill in the bracketed fields and mail certified mail (return receipt requested) to create paper trail.**

**Track everything - VA claims live and die by documentation!**