Sample letter requesting medical records

Last updated on July 29, 2022

Here are some sample letters requesting medical records. It should be written in a formal business style and sent by certified mail.

Sample 1 - medical records request letter

Your Name
Your 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
Your Name
List of enclosures if an addressed envelope is enclosed or a medical release form

Sample 2 - medical records request letter

Your Name
Your 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,

As permitted by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services rules, the objective of this letter is to obtain copies of my medical records.

I received care from you between [fill in the dates] in your facility [in your location]. I want copies of the following health documents linked to my care, or all of them.

I understand that you may charge a fair cost for copies of the records but not for the time it takes to find them. Send me the required records by mail at the aforementioned address. You can also be charged postage if you ask for the records to be mailed. *

I anticipate receiving the aforementioned records within the allotted 30 days under HIPAA. Please let me know in writing if my request cannot be fulfilled within 30 days, along with a potential delivery date for my records.

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 - medical records request letter

1111 Cherry Ln.
Madison, WI 53705

July 10, 2022

Mary Johnson
New Visions Eye Center
789 Elm St.
Madison, WI 53705

Dear Mary,

I give New Visions Eye Center permission to release all of my medical records and transmit them to Pathfinder Clinic, 1234 Rose Road, Madison, WI 53705 in accordance with HIPAA regulations and Department of Health guidelines. You can find my entire name at the end of this letter. My birthday is November 13, 2001.

If you have questions or need more information you may call me at (608) 141-1111.

Sincerely,

Signature
Your Name
List of enclosures if an addressed envelope is enclosed or a medical release form

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