Learn how to write a letter to request medical records. Make your request letter using our sample letter to request medical records as a guide.
Sample 1 - Letter to Request Medical Records from Hospital
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Name of Hospital]
[Address]
[City, State, Zip Code]
RE: Requesting copies of my medical records. ID number: NUMBER
Dear ________,
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 [Hospital] 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,
Signature
Your Name
List of enclosures if an addressed envelope is enclosed or a medical release form
Sample 2 - Letter to Request Medical Records from Doctor
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Doctor’s Name]
[Address]
[City, State, Zip Code]
RE: Requesting copies of my medical records. ID number: NUMBER
Dear [Doctor’s Name],
I am writing to request copies of my medical records. I understand that I am entitled to receive a copy of my medical records under the [Name of Act or Law], and I am requesting that you provide me with copies of all of my records in your possession.
If you need any additional information from me in order to fulfill this request, please let me know. I can be reached at [Your Phone Number] or [Your Email].
Thank you for your time attending to this matter.
Sincerely,
Signature
Your Name
List of enclosures if an addressed envelope is enclosed or a medical release form
Sample 3 - Letter Requesting Medical Records of Deceased
[Your Name]
[Your Address]
[City, State, Zip Code]
[Date]
[Doctor’s Name]
[Address]
[City, State, Zip Code]
RE: Requesting copies of deceased medical records. ID number: NUMBER
Dear [Doctor’s Name],
I am writing to request copies of the medical records of my deceased relative, [Deceased Relative’s Name]. I am the [Relationship to Deceased, e.g. “executor of their estate”], and I am entitled to receive a copy of their medical records under the [Name of Act or Law].
I understand that the release of medical records for a deceased individual may require additional steps and documentation. If you need any additional information from me in order to fulfill this request, please let me know. I can be reached at [Your Phone Number] or [Your Email].
Thank you for your time attending to this matter.
Sincerely,
Signature
Your Name
List of enclosures if an addressed envelope is enclosed or a medical release form
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