Medical Records Request Letter [FREE Sample]

Learn how to write a medical records request letter. Use our sample medical records request letter as a template for your request letter.

Medical Records Request Letter sample

Your Name
Your Address
City, State, Zip Code

DATE

Name of Healthcare provider
Name of Hospital or other Facility if applicable
Address of Healthcare provider
City, State, Zip Code

RE: Requesting copies of my medical records. ID number: NUMBER

Dear Name of Healthcare Provider,

I am writing this letter to request copies of any medical records of mine that you have. 

I have understood that according to the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations, I am entitled to have copies of my medical records.

I was treated in your FACILITY from DATE to DATE. I would like copies of all of my blood test results, imaging studies, operative reports, as well as notes from doctors and nurses, consultations with specialists, referrals and any other record in my medical file.

I understand you may charge a reasonable fee for copying the records, as well as for postage to mail the reports to the above address. However, you will not charge for time spent locating the records. 

I hope to receive the above records within 30 days as specified under HIPAA or receive a letter stating the reason for any delay. I can be reached at 555-123-4567 or a Name@email.com if you have any questions.

Thank you for your time attending to this matter.

Sincerely, 

Your Signature
Your Printed name
List of enclosures if an addressed envelope is enclosed or a medical release form