Moscow Healthcare Department
State Budgetary Healthcare Institution
“City Clinical Hospital № 52 of
Moscow Healthcare Department”
(MCCH52)
3 Pekhotnaya Street, Moscow 123182 Russia
Tel.: +7 495 870-36-07
Fax: +7 499 196-21-14
Web: http://52gkb.ru, e-mail: gkb52@zdrav.mos.ru
OKPO 01934495 PSRN 1027739078652
TIN/IEC 7734115329/773401001
Date ______
Patient’s Full Name
(as in ID document)
Email
Tel.
Document № ________
Medical Appointment Letter
On behalf of Moscow City Clinical Hospital № 52 (further referred to as MCCH52), we inform
that______ (Patient’s full name, date of birth, ID number, citizenship, place of birth, insurance certificate
number valid in Russia (if applicable), visa number (if applicable) has been appointed to undergo
__________ (examination, consultation, treatment, etc.) at __________ (department or center) in MCCH52
located at 3, Pekhotnaya Street, Moscow, Russia.
MCCH52 also indicates the readiness to provide the above patient with _____ (a list of medical services
and procedures only in case the patient has signed Consent to the processing of personal data).
Approximate dates of the visit to MCCH52 are from ________to ______. The range of medical services
and the duration of the patient’s stay at MCCH52 may be subject to change depending on the results of the
examinations, treatment methods and the course of the patient’s condition.
Additionally, we inform you about the need for an accompanying person in case of the patient’s
transportation, including the justification for the assistance (if applicable). The accompanying person is
_____________ (Full name, date of birth, ID number, citizenship, place of birth, visa number (if
applicable).
We justify the medical necessity for undergoing treatment at the Medical Institution under the conditions
of restrictions associated with the spread of the novel coronavirus infection COVID-19. When entering the
Russian Federation patient (Full name) ensures to have a medical document in the Russian language or
verified translation of the document into Russian, confirming the negative result of a laboratory study of
the material for the novel coronavirus infection COVID-19.
This letter does not commit the hospital to any kind of financial support or hosting arrangements
for the patient or their guardians, nor does it guarantee an entry visa.
Please, do not hesitate to contact us should any additional information be required to ensure the
approval of the planned medical care. An authorized point of contact at MCCH52: _____________
(name, position, phone number, e-mail).
To whom it may concern
Chief Medical Officer
Mariana A. Lysenko