Nassau New York Ejemplo de carta de solicitud de registros médicos - Sample Letter for Request for Medical Records

• Category: Cartas - No legales - Solicitudes
• State: Multi-State
• County: Nassau
• Control #: US-0546LR
• Format: Word

Description

Carta de solicitud de registros médicos. Subject: Request for Medical Records — Nassau, New York Dear [Medical Facility/Healthcare Provider], I hope this letter finds you well. I am writing to request access to my medical records as permitted by the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. I understand that as a patient, I have the right to review and obtain copies of my medical records upon request. Therefore, I kindly ask that you provide me with the following information: 1. Patient Information: — Full Name— - Date of Birth: - Social Security Number (optional): — Address— - Phone Number: 2. Relevant Medical Information: — Dates of treatment— - Specific medical conditions or procedures: — Attending physician(s)— - Hospital or clinic name (if applicable): 3. Type of Records Requested: — Comprehensive medical records, including but not limited to: — Consultation note— - Progress notes - Test results — X-rays and imaging report— - Laboratory reports — Surgical record— - Medication history - Discharge summaries 4. Purpose of Request: — Personareferencenc— - Continuity of care — Legal/insurance claim— - Second opinion — Research purposes 5. Preferred Delivery Method: — Digital copies (CD/DVD, email— - Paper copies (mailed to the address provided) — Secure online portal access (if available) — In-person pickup (if applicable) 6. Authorization and Verification: — Please find enclosed a completed authorization form or provide instructions on how to complete it online. — I understand that there may be charges associated with fulfilling this request, and I am willing to pay reasonable fees for copying and postage, if applicable. Please note that the timeframe for providing me with the requested medical records should not exceed 30 days from the date of this letter, as outlined by HIPAA regulations. If it is not possible to fulfill my request within this timeframe, please notify me in writing and provide an estimated timeline. I appreciate your attention to this matter and your assistance in providing me with access to my medical records. If you have any questions or require additional information, please do not hesitate to contact me at [phone number] or [email address]. Thank you for your prompt attention to this request. Sincerely, [Your Full Name] [Date]

Subject: Request for Medical Records — Nassau, New York Dear [Medical Facility/Healthcare Provider], I hope this letter finds you well. I am writing to request access to my medical records as permitted by the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. I understand that as a patient, I have the right to review and obtain copies of my medical records upon request. Therefore, I kindly ask that you provide me with the following information: 1. Patient Information: — Full Name— - Date of Birth: - Social Security Number (optional): — Address— - Phone Number: 2. Relevant Medical Information: — Dates of treatment— - Specific medical conditions or procedures: — Attending physician(s)— - Hospital or clinic name (if applicable): 3. Type of Records Requested: — Comprehensive medical records, including but not limited to: — Consultation note— - Progress notes - Test results — X-rays and imaging report— - Laboratory reports — Surgical record— - Medication history - Discharge summaries 4. Purpose of Request: — Personareferencenc— - Continuity of care — Legal/insurance claim— - Second opinion — Research purposes 5. Preferred Delivery Method: — Digital copies (CD/DVD, email— - Paper copies (mailed to the address provided) — Secure online portal access (if available) — In-person pickup (if applicable) 6. Authorization and Verification: — Please find enclosed a completed authorization form or provide instructions on how to complete it online. — I understand that there may be charges associated with fulfilling this request, and I am willing to pay reasonable fees for copying and postage, if applicable. Please note that the timeframe for providing me with the requested medical records should not exceed 30 days from the date of this letter, as outlined by HIPAA regulations. If it is not possible to fulfill my request within this timeframe, please notify me in writing and provide an estimated timeline. I appreciate your attention to this matter and your assistance in providing me with access to my medical records. If you have any questions or require additional information, please do not hesitate to contact me at [phone number] or [email address]. Thank you for your prompt attention to this request. Sincerely, [Your Full Name] [Date]

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.