[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records in accordance with my rights under the Health Insurance Portability and Accountability Act (HIPAA) and the Florida state law. I have been a patient at your facility, and I would greatly appreciate your assistance in providing me with the following documentation: 1. Cover Letter: This is a brief letter addressing the purpose of the request and providing clear instructions to the medical provider. 2. Authorization Form: In order to comply with HIPAA regulations, I have attached a completed and signed Authorization for Release of Medical Records form, granting permission for the disclosure of my medical records. 3. Identification: A copy of my valid identification, such as a driver's license or passport, is attached for verification purposes. 4. Medical Records: I kindly request the release of all relevant medical records, including but not limited to the following: — Physician note— - Progress notes - Admission and discharge summaries — Surgical and procedural report— - Laboratory and diagnostic test results — Radiology reports and image— - Medication and treatment records — Immunization record— - Allergies and immunizations — Consultation report— - Referral letters — Rehabilitation and physical therapy records — Mental health records (if applicable) It is important that the records be provided in an organized manner and that they include the most recent information available. If there are any associated fees for copying or preparing the records, please inform me in advance. Please send the requested records to the address stated above or provide instructions for collecting them personally from your office. I would appreciate if the records could be provided within the statutory time frame of 30 days. If this timeline cannot be met, kindly inform me promptly and provide an estimated date of completion. I understand that there might be certain redactions made to sensitive information as per HIPAA privacy guidelines, and I appreciate your diligence in ensuring patient confidentiality. Thank you for your attention to this matter. Should you require any additional information or have any concerns, please do not hesitate to contact me at the phone number or email address provided. I look forward to receiving my medical records in a timely manner so that I can continue managing my healthcare effectively. Your cooperation and prompt response in this matter are greatly appreciated. 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.Miami-Dade Florida Ejemplo de carta de solicitud de registros médicos - Sample Letter for Request for Medical Records
Category:
State:
Multi-State
County:
Miami-Dade
Control #:
US-0546LR
Format:
Word
Instant download
Description
Carta de solicitud de registros médicos.
[Your Name] [Your Address] [City, State, ZIP] [Email Address] [Phone Number] [Date] [Medical Provider's Name] [Medical Provider's Address] [City, State, ZIP] Subject: Request for Medical Records Dear [Medical Provider's Name], I hope this letter finds you well. I am writing to request copies of my medical records in accordance with my rights under the Health Insurance Portability and Accountability Act (HIPAA) and the Florida state law. I have been a patient at your facility, and I would greatly appreciate your assistance in providing me with the following documentation: 1. Cover Letter: This is a brief letter addressing the purpose of the request and providing clear instructions to the medical provider. 2. Authorization Form: In order to comply with HIPAA regulations, I have attached a completed and signed Authorization for Release of Medical Records form, granting permission for the disclosure of my medical records. 3. Identification: A copy of my valid identification, such as a driver's license or passport, is attached for verification purposes. 4. Medical Records: I kindly request the release of all relevant medical records, including but not limited to the following: — Physician note— - Progress notes - Admission and discharge summaries — Surgical and procedural report— - Laboratory and diagnostic test results — Radiology reports and image— - Medication and treatment records — Immunization record— - Allergies and immunizations — Consultation report— - Referral letters — Rehabilitation and physical therapy records — Mental health records (if applicable) It is important that the records be provided in an organized manner and that they include the most recent information available. If there are any associated fees for copying or preparing the records, please inform me in advance. Please send the requested records to the address stated above or provide instructions for collecting them personally from your office. I would appreciate if the records could be provided within the statutory time frame of 30 days. If this timeline cannot be met, kindly inform me promptly and provide an estimated date of completion. I understand that there might be certain redactions made to sensitive information as per HIPAA privacy guidelines, and I appreciate your diligence in ensuring patient confidentiality. Thank you for your attention to this matter. Should you require any additional information or have any concerns, please do not hesitate to contact me at the phone number or email address provided. I look forward to receiving my medical records in a timely manner so that I can continue managing my healthcare effectively. Your cooperation and prompt response in this matter are greatly appreciated. Sincerely, [Your Name]
