SAMPLE Letter of Representation for ACME Organization

123 Main Street | 5th Floor | Ste 100 | Los Angeles, CA 90015

09/17/2021

To Whom It May Concern:



Please be advised that hXe, LLC has been designated as an authorized representative of ACME Organization in the matter of securing medical records electronically through the hXe platform. The purpose of this letter is to provide medical service providers with written proof of the authorization of hXe, LLC by ACME Organization to obtain medical records from medical service providers and have said records delivered through the hXe platform. ACME Organization, as well as, hXe, LLC are aware of the privacy and confidentiality issues surrounding personal health information as outlined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and other applicable laws and regulations. The records being sought are for the sole use of ACME Organization as authorized by the patient, or his/her legal representative.

This letter of representation is to remain in effect until further notice.

Sincerely,

/JXD/

Jane Doe

ACME Organization