3 Proven Templates for Medical Record Requests

When requesting medical records from a doctor, it’s important to be clear, concise, and to provide all necessary information to facilitate the process. Below are three template options you can customize for your specific situation.

Template 1: Direct Request





[Your Full Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Doctor’s Full Name]
[Practice or Hospital Name]
[Address]
[City, State, ZIP Code]

Dear Dr. [Doctor’s Last Name],

I am writing to request a copy of my medical records related to my treatment under your care from [Start Date] to [End Date]. I require these records for [Specify Reason: personal use, continuing care, second opinion, etc.].

According to the Health Insurance Portability and Accountability Act (HIPAA), I understand I have the right to access these records. Please include all pertinent documents, including but not limited to clinical notes, lab reports, imaging studies, and a list of medications prescribed.


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If there are any fees associated with the copying of these records, kindly inform me beforehand. I would appreciate it if the records could be sent to me by [specify delivery method: email, postal mail, etc.] to the address listed above.

Should you need any further information or clarification to process this request, please do not hesitate to contact me at [Your Phone Number] or [Your Email Address].

Thank you for your prompt attention to this matter.

Sincerely,

[Your Name]


Template 2: Request for Electronic Health Records

[Your Full Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Doctor’s Full Name]
[Practice or Hospital Name]
[Address]
[City, State, ZIP Code]

Dear Dr. [Doctor’s Last Name],

I hope this letter finds you well. As a patient who values the continuity of care and personal health management, I am requesting electronic copies of my complete medical records under your care from [Start Date] to [End Date]. The records are needed for [Specify Reason: personal health records, sharing with another physician, etc.].

In compliance with the Health Insurance Portability and Accountability Act (HIPAA), I would like to receive these records in an electronic format, preferably as PDF files via email to [Your Email Address], or through a secure patient portal if available.

Please include all detailed records and reports, such as diagnostic images, test results, consultation notes, and treatment plans.

Should there be any costs associated with processing this request, kindly notify me in advance. Additionally, if any forms need to be completed on my end, please send them over or guide me on the next steps.

Thank you very much for your cooperation and assistance in this matter. Please contact me if you require any further information or verification.

Warm regards,

[Your Name]


Template 3: Request with Authorization Form

[Your Full Name]
[Your Address]
[City, State, ZIP Code]
[Phone Number]
[Email Address]
[Date]

[Doctor’s Full Name]
[Practice or Hospital Name]
[Address]
[City, State, ZIP Code]

Dear Dr. [Doctor’s Last Name],

I am reaching out to formally request the release of my medical records pertaining to my treatment from [Start Date] to [End Date]. These records are being requested for [Specify Reason: insurance purposes, new medical provider, etc.].

Enclosed with this letter, you will find a signed authorization form granting permission for the release of these records to myself or directly to [Third Party’s Name and Address, if applicable].

I request that the following specific documents be included in the records provided:

  • Clinical notes and correspondence
  • Laboratory test results
  • Imaging studies (X-rays, MRIs, CT scans, etc.)
  • List of medications prescribed
  • Surgical reports and discharge summaries

If there are any fees for the preparation or sending of these records, please inform me of the total cost prior to proceeding. I prefer to receive the records via [specify method: mail, secure email, etc.].

Please feel free to contact me at [Your Phone Number] or [Your Email Address] should you need further information or any additional documentation from my side.

Thank you for your attention to this request and for your ongoing care.

Sincerely,

[Your Name]
[Enclosures: Authorization Form, if applicable]


Each template addresses the core elements of a medical record request: identification of the requester and the physician, the specific time frame and types of records requested, the method of delivery, and any legal or procedural considerations. 

Adjust the templates as needed to suit the specifics of your request and ensure compliance with any additional requirements your healthcare provider may have.

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