Medical Release Letter [Sample]

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

Medical Release Letter Template

[Applicant’s Name]
[Applicant’s Address]
[City, State, Zip Code]


[Hospital’s Name]
[City, State, Zip Code]

RE: [Medical identification number] – [Date of Birth]

Dear [Hospital Record’s Department]:

I am writing this letter to request copies of my medical records that are in [Name of Hospital]. I understand that the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations allow me to have these copies.

I received treatment in your facilities from [Date, Year to Date, Year]. I would like to have copies of all my records that relate to this treatment. This may include the medical history I previously provided to you, consultations with specialists and test results.

I will be happy to pay a fee for copying the records and for postage to send them to the above address.

According to the HIPAA, I can expect to receive my medical records within 30 days. It this is not possible, kindly inform me in writing and tell me when to expect the records.

If you have any questions or require more information, call me at [555 123 4567] or email me at [].

Thank you for your time.


[Name in print]
Medical release form enclosed

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