Second Opinion Request Letter

[Date] [Cancer Center / Physician Name] Attn: New Patient Intake / Second Opinion Program [Address] Re: Request for Second Opinion Consultation Patient Name: [Full Name] Date of Birth: [DOB] Diagnosis: [Cancer type, stage, key biomarkers] Date of Diagnosis: [Date] Dear [Center / Doctor], I am writing to request a second opinion consultation for [my / my family member's] cancer diagnosis. The treating team at [Current Practice] has recommended [current proposed treatment plan]. Before proceeding, I would value an independent expert review. I am specifically interested in: • Confirmation of the diagnosis and stage based on pathology re-review • Whether all appropriate biomarker / genomic testing has been completed • Whether there are alternative treatment approaches not yet considered • Whether I am eligible for any clinical trials, at your center or elsewhere • Your team's recommended treatment sequence Records I am sending with this request (please confirm receipt): 1. Pathology report and (if requested) original slides or blocks 2. Complete imaging reports and discs (CT / MRI / PET) 3. Operative and procedure notes 4. Treatment summary to date (drugs, doses, dates, response) 5. Recent labs (last 3 months) 6. List of current medications and supplements 7. Insurance card (front and back) Please advise: • What date is available for an in-person or telehealth consultation • Whether additional records are needed • Whether prior authorization is required from my insurance I can be reached at [phone] or [email]. Thank you for your consideration. Sincerely, [Patient or Representative Signature] [Printed Name] [Address] [Phone] · [Email]

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: [Full Name] Date of Birth: [DOB] Address: [Address] I authorize [Releasing Provider — current oncology practice or hospital] to release a complete copy of my medical records to: [Receiving Provider Name] [Receiving Provider Address] Attn: Medical Records / Second Opinion Program Fax / Secure Portal: [If known] Records to be released (check all that apply): ☐ Office visit notes (last 12 months) ☐ Pathology reports and slides ☐ Imaging reports and CDs (CT, MRI, PET, ultrasound) ☐ Operative and procedure notes ☐ Lab results (last 12 months) ☐ Treatment summary ☐ Genetic / genomic / biomarker testing results This authorization expires [date — usually 12 months from signing] and may be revoked in writing at any time. ____________________________________ ___________________ Patient (or Authorized Representative) Date ____________________________________ Printed Name & Relationship to Patient