Medical Records Request Letter [Free Samples]

Find out how to draft a medical records request letter in this article. For your medical records request letter, use our sample medical records request letters as templates.

sample 1 – Medical Records request Letter

[Your Name]
[Your  Address]
[City, State, Zip Code]

[Date]

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

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

Dear [Hospital Record 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 [name@email.com].

Thank you for your time.

Sincerely,

[Signature]
[Your Name]
Medical release form enclosed

Sample 2 – Medical Records request Letter

[Your Name]
[Your  Address]
[City, State, Zip Code]

[Date]

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

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

Dear [Hospital Record Department]:

I’m writing to have copies of my medical records sent to me. On [date], I was treated in your office. Please send all of my medical records, test results, and consultation notes, as well as any referrals.

I realize that for the copying of my medical records, I may be charged a reasonable fee. I should not be charged for any time spent locating my records, however.

Please send the needed information to the above-mentioned address. For your convenience, I’ve included a self-addressed envelope.

Thank you for your time.

Regards,

[Signature]
[Your Name]
Medical release form enclosed

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