Franklin Ohio 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: Franklin
• Control #: US-0328LR
• Format: Word

Description

Carta solicitando registros médicos del paciente. Dear [Healthcare Provider/Healthcare Facility], I am writing to request a copy of my medical records for myself or to [name of individual requesting on behalf of patient]. I am a patient at your facility and would like to obtain a complete set of my medical records for personal use or for [name of healthcare provider requesting on behalf of patient]. I understand that I have the right to access my medical records under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Furthermore, I kindly ask that you provide me with the following information: 1. Patient Information: — Full Name— - Date of Birth: - Social Security Number (optional): — Address: 2. Dates of Treatment: Please provide the range of dates during which I received medical care at your facility. If possible, include specific appointments or hospitalizations. 3. Types of Medical Records: I request copies of all medical records pertaining to my treatment. This includes, but is not limited to, the following: — Office visit note— - Lab test results - Radiology reports — Surgical report— - Consultation notes - Progress notes — Pathology report— - Immunization records — Medication histor— - Discharge summaries — Any other relevant medical documents 4. Delivery Method: Please inform me of the available options for receiving the medical records. You may choose to mail them to the address provided above or provide a secure online platform to access the records digitally. 5. Fees: If there are any costs associated with fulfilling this request, please provide an itemized breakdown of the fees. I understand that HIPAA allows for reasonable fees to cover the cost of preparing and copying records, but I would appreciate knowing the total amount in advance. If possible, please estimate the total cost based on the number of pages or time required to gather the records. 6. Authorization: If required, please provide any necessary authorization forms that need to be completed to release the medical records. Kindly notify me if such forms are needed and include instructions on how to properly complete and return them. 7. Timeline: I kindly request that you provide me with an estimated timeline for when I can expect to receive the requested medical records. I understand that obtaining and compiling the records may take some time, but I would appreciate an approximate timeframe to manage my expectations. Thank you for your attention to this matter. I trust that you will handle my request promptly and in accordance with all applicable laws and regulations. Please do not hesitate to contact me if you need any further information or have any questions regarding this request. I can be reached at [phone number] or [email address]. Sincerely, [Patient's Name or Authorized Individual]

Dear [Healthcare Provider/Healthcare Facility], I am writing to request a copy of my medical records for myself or to [name of individual requesting on behalf of patient]. I am a patient at your facility and would like to obtain a complete set of my medical records for personal use or for [name of healthcare provider requesting on behalf of patient]. I understand that I have the right to access my medical records under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Furthermore, I kindly ask that you provide me with the following information: 1. Patient Information: — Full Name— - Date of Birth: - Social Security Number (optional): — Address: 2. Dates of Treatment: Please provide the range of dates during which I received medical care at your facility. If possible, include specific appointments or hospitalizations. 3. Types of Medical Records: I request copies of all medical records pertaining to my treatment. This includes, but is not limited to, the following: — Office visit note— - Lab test results - Radiology reports — Surgical report— - Consultation notes - Progress notes — Pathology report— - Immunization records — Medication histor— - Discharge summaries — Any other relevant medical documents 4. Delivery Method: Please inform me of the available options for receiving the medical records. You may choose to mail them to the address provided above or provide a secure online platform to access the records digitally. 5. Fees: If there are any costs associated with fulfilling this request, please provide an itemized breakdown of the fees. I understand that HIPAA allows for reasonable fees to cover the cost of preparing and copying records, but I would appreciate knowing the total amount in advance. If possible, please estimate the total cost based on the number of pages or time required to gather the records. 6. Authorization: If required, please provide any necessary authorization forms that need to be completed to release the medical records. Kindly notify me if such forms are needed and include instructions on how to properly complete and return them. 7. Timeline: I kindly request that you provide me with an estimated timeline for when I can expect to receive the requested medical records. I understand that obtaining and compiling the records may take some time, but I would appreciate an approximate timeframe to manage my expectations. Thank you for your attention to this matter. I trust that you will handle my request promptly and in accordance with all applicable laws and regulations. Please do not hesitate to contact me if you need any further information or have any questions regarding this request. I can be reached at [phone number] or [email address]. Sincerely, [Patient's Name or Authorized Individual]

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.