1. Ziegler-Niebur Medical Group
Dora Deras
1711 West County Road B
Roseville, MN 55113
December 12, 2013
Jane Carlson
546 Highcrest Avenue
Roseville, MN 55113
Dear Ms. Carlson:
Thank you for sending your request letter. I will be very happy to help you with this request
process. But, before I send your medical records, I need you to sign a medical request form.
The purpose for this is to keep your records private and make sure they get to the right hands.
The form and a self-addressed, stamped envelope are enclosed with this letter. Please make sure
to use this envelope, so it can be directly delivered to medical records. The processing will take
approximately 10-15 business days (2-3 weeks). Please send them on time to keep your
appointment with the specialist.
Accuracy is important for faster processing. Please complete the form with following
instructions.
 Complete the first five lines with your information.
 Check the box that states “release information to the following party.”
 Next to “Name”, write Peterson Medical Group corresponding information.
 Answer the two questions stating what records you need and the reason.
 Sign and date the form.
 Obtain witness signature by a friend or family member.
You can contact Medical Records at 651-555-6785 from 8:30 a.m. to 4:00 p.m. if you have
questions regarding the transferred records.
You are very important to us. Thank you for trusting us with your care needs. If you have any
questions, please call me at 651-222-4554. I am looking forward to help you any time.
Sincerely,
Dora Deras
Medical Assistant
Enclosures (2)