[Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Name of Medical Facility] [Address of Medical Facility] [City, State, ZIP Code] Attention: Medical Records Department Subject: Request for Medical Records Dear Sir/Madam, I hope this letter finds you well. I am writing to formally request copies of my medical records, pertaining to my treatment at your esteemed medical facility. I believe it is essential to have a comprehensive understanding of my medical history as I continue to seek appropriate healthcare. Furthermore, I have provided the necessary information below to facilitate the retrieval of my medical records: 1. Full Name: [Your Full Name] 2. Date of Birth: [Your Date of Birth] 3. Address: [Your Current Address] 4. Social Security Number: [Your Social Security Number] 5. Medical Record Number (if applicable): [Your Medical Record Number, if known] Please include the following information in the copies of my medical records: 1. Consultation notes from all healthcare providers 2. Diagnostic reports, including laboratory results, X-rays, MRI scans, etc. 3. Surgical reports, if any 4. Prescription and medication history 5. Immunization records 6. Treatment plans and progress notes 7. Any other relevant medical documentation I request that you provide the copies of my medical records in an electronic format, preferably by email or a secure online platform. If electronic delivery is not available, please inform me of the alternative options. If there are any fees associated with retrieving or providing copies of my medical records, please inform me in advance. I am willing to cover reasonable costs as permitted by Connecticut state law. I would appreciate receiving my medical records within the shortest time frame possible, preferably within 30 days of receiving this letter. If you foresee any delays, kindly inform me of the reasons for such delays and provide an estimated timeline for when I can expect to receive the requested medical records. Should you require any additional information or if there are any questions regarding my request, please do not hesitate to contact me at the phone number or email address provided above. Thank you for your attention to this matter. I expect a prompt response and your cooperation in ensuring that I can access the medical records in a timely manner. Sincerely, [Your Name]
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.Connecticut Ejemplo de carta de solicitud de registros médicos - Sample Letter for Request for Medical Records
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