Ann W. Ayers, M.D.
5816 Auburn Avenue,
Cincinnati, Ohio 45205
Dear Dr. Ayers:
RE: MELANIE M. HILL
We have been employed by the above-referenced individual who was injured in an automobile collision on January 10, 2005. After going to Central Hospital, she was referred to you; and I understand that you have been treating him since that time.
Please send me a medical report including the diagnosis after the first visit, the history taken at the first visit, treatment rendered including medication, physical therapy, and the prognosis. Please indicate whether or not he is likely to retain any impairment or disability.
We will need a copy of your bill to forward to the insurance company, even though I understand that the statement may be sent to Mr. Hill’s personal insuror through her work. The statement should list the date and cost of each service rendered and total charges.
Enclosed is an authorization signed by our client granting you permission to release medical information concerning his physical condition and treatment and medical records. If there is a charge for the medical report, please let me know immediately
ELIZABETH M. CALDWELL, ESQ.
Enclosure: Medical Authorization
c: Melanie M. Hill
This is to authorize any physician or representative of any hospital or clink or any other health care provider to furnish Elizabeth M. Caldwell, Esq., 811 Vine Street, Suite A-3, Cincinnati, Ohio, 45202 any information or opinion that he may request regarding my physical condition and treatment which has been rendered to me and to allow her to see and copy any X-rays or medical records available regarding my condition and my treatment.
This authorization is valid for three (3) years following its date of execution.
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