Sample report outline

• Author: Scott M. Riemer/Jennifer L. Hess
• Pages: 242-242

Form 11 ERISA Disability Claims and Litigation A-224

FORM 11 SAMPLE REPORT OUTLINE

DATE, 202X

Dr. NAME

Address

Re: PATIENT NAME (DOB: xx/xx/xx)

REQUEST FOR QUESTIONNAIRE AND NARRATIVE REPORT

Dear Dr. NAME:

We are the attorneys for your patient, CLIENT, in his/her claim for disability bene-





write to request: (1) a report addressing CLIENT’s disability and assessment of his/

her ability to work; (2) a completed questionnaire (enclosed); and (3) your current



These requests are being made because it is imperative that your opinion as CLI-



list of the topics that your narrative report should address:

• Diagnosis and prognosis.

• Length of care.

• Patient’s relevant medical history.

 

• Description of symptoms.

 

 

 

 

• Other information worthy of being highlighted.

We would greatly appreciate the opportunity to review a draft of your narrative



   

request. We deeply appreciate your cooperation as we attempt to reinstate [CLI-



Sincerely yours,