[Sample] Dental Records Request Letter

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

Sample Dental Records Request Letter

Rudy Parker
1219 Wooden Road
Pleasant Hill, NJ, 08046

May 18, 2020

Dr. Benson
Happy Smile
2400 Cherry Road
Pleasant Hill, NJ, 08046

RE: Requesting copies of my dental records. ID number: #234654

Dear Dr. Benson,

I am writing this letter to request copies of any dental 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 dental records.

I was treated in your dental office from 01/01/2016 to 04/01/2020. I would like copies of all of my dental records including, consultations with specialists, referrals and any other record in my 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 555-153-4567 or a rudy@email.com if you have any questions.

Thank you for your time attending to this matter.

Sincerely,

Signature
Rudy Parker
List of enclosures if an addressed envelope is enclosed or a medical release form

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