[Sample] Authorization Letter to Get Medical Records

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

Sample Authorization Letter To Get Medical Records

[Individual’s Name]
[Individual’s 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, 

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

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