Allegheny Pennsylvania Ejemplo de carta de solicitud de registros médicos del paciente - Sample Letter for Request for Patient Medical Records

• Category: Cartas - No legales - Médicas
• State: Multi-State
• County: Allegheny
• Control #: US-0328LR
• Format: Word

Description

Carta solicitando registros médicos del paciente. [Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Name of Medical Facility] [Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Name of Medical Records Department], I hope this letter finds you in good health. I am writing to formally request a copy of my medical records from [Name of Medical Facility]. I believe it is important for individuals to have access to their complete medical history as it promotes continuity of care and enables patients to make informed healthcare decisions. Please find below the relevant details regarding the release of my medical records: Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN] (optional) — Address: [Patient's Address— - Contact Number: [Patient's Phone Number] — Email Address: [Patient's Email Address] (optional) Dates of Medical Treatment: I am requesting all medical records for the following period: — From [Start Date] to [End Date] Types of Medical Records Requested: Please include the following documents in the medical records package: — Consultation note— - Laboratory and diagnostic test results — Radiology reports and imaginstudiedie— - Progress reports — Surgical repo—ts - Discharge summaries — Medication and prescriptiohistoryor— - Immunization records — Allergies and adverse reaction— - Pathology reports — Any other relevant medical documents Purpose of Request: [Specify the reason for the medical records request, e.g., for personal records, specialist consultation, second opinion, legal proceedings, etc.] Preferred Format: To facilitate easier handling and transportation, I kindly request the medical records to be provided in an electronic format (PDF file) via secure email or on a CD-ROM. If there are any additional costs associated with the production of the medical records, please inform me in advance. Authorization: I authorize you to release my medical records to me or to the healthcare providers I designate for continuity of care purposes. To validate this request, I have enclosed a copy of my photo identification [or any other required documents or forms] with this letter. Delivery Address: Please send the medical records to the following address: [Your Address] [City, State, ZIP] If you have any questions or require further information, please do not hesitate to reach me at [Your Phone Number] or via email at [Your Email Address]. Your prompt attention to this request would be greatly appreciated. Thank you for your cooperation and assistance in providing me with my medical records. I look forward to receiving the requested records within the legally mandated time frame. Sincerely, [Your Name]

[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Name of Medical Facility] [Address] [City, State, ZIP] Subject: Request for Patient Medical Records Dear [Name of Medical Records Department], I hope this letter finds you in good health. I am writing to formally request a copy of my medical records from [Name of Medical Facility]. I believe it is important for individuals to have access to their complete medical history as it promotes continuity of care and enables patients to make informed healthcare decisions. Please find below the relevant details regarding the release of my medical records: Patient Information: — Full Name: [Patient's Full Name— - Date of Birth: [Patient's Date of Birth] — Social Security Number: [Patient's SSN] (optional) — Address: [Patient's Address— - Contact Number: [Patient's Phone Number] — Email Address: [Patient's Email Address] (optional) Dates of Medical Treatment: I am requesting all medical records for the following period: — From [Start Date] to [End Date] Types of Medical Records Requested: Please include the following documents in the medical records package: — Consultation note— - Laboratory and diagnostic test results — Radiology reports and imaginstudiedie— - Progress reports — Surgical repo—ts - Discharge summaries — Medication and prescriptiohistoryor— - Immunization records — Allergies and adverse reaction— - Pathology reports — Any other relevant medical documents Purpose of Request: [Specify the reason for the medical records request, e.g., for personal records, specialist consultation, second opinion, legal proceedings, etc.] Preferred Format: To facilitate easier handling and transportation, I kindly request the medical records to be provided in an electronic format (PDF file) via secure email or on a CD-ROM. If there are any additional costs associated with the production of the medical records, please inform me in advance. Authorization: I authorize you to release my medical records to me or to the healthcare providers I designate for continuity of care purposes. To validate this request, I have enclosed a copy of my photo identification [or any other required documents or forms] with this letter. Delivery Address: Please send the medical records to the following address: [Your Address] [City, State, ZIP] If you have any questions or require further information, please do not hesitate to reach me at [Your Phone Number] or via email at [Your Email Address]. Your prompt attention to this request would be greatly appreciated. Thank you for your cooperation and assistance in providing me with my medical records. I look forward to receiving the requested records within the legally mandated time frame. 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.